A Healthcare Management Company

This process involves individual claims audits, negotiation, and proactive support for high-cost claimants - functions legacy insurance carriers aren’t built for. By focusing on smart technology and human expertise rather than discounts and auto-adjudication, companies outperform average PEPY costs and in 2018, realized up to 14% additional savings beyond network discounts. The importance of independence. These savings are possible when employers align themselves with independent carriers and administrators who act independently from the provider contracts. For many legacy partnerships (traditional carriers), there is no aligned interest between the administrator and the company, and thus no motivation to discover additional savings. Partner with a proven, independent entity to maximize your opportunity.

Sample Audit:

Summary 1:

  • Member treated at a hospital facility in central California
  • Member was treated for chronic cholecystitis (chronic gallbladder issues common with recurring gall stones)
  • Member received surgery which was charged at $15,825.44 (billed charges)
  • Hospital facility then unbundled the same charges and billed them separately aka Unbundled Charges
  • Total billed charges: $56,849.64
  • Insurance paid: $56,944.34 – Why? Auto Adjudication? MLR?
  • After our audit and RBP adjudication, Total Amount Plan Saved: $50,944.34

Study Conclusions:
These are charges that never should have been included in the bill. However, Auto Adjudication and Legacy Carriers pay these excess claims.