EthiCare performed a Medical Bill Review (“MBR”) Audit on the claim in question and uncovered $934,000 in billing and coding issues. It should be noted that EthiCare’s fee for performing the MBR Audit was only $5,000.
Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement and cost containment company that help payors save money by focusing on the claims that ruin loss ratios, namely, catastrophic claims over $100,000 and the ultra-expensive dialysis claims. EthiCare is an independent, owner-operated private corporation and is a three time honoree of the Inc. 500|5000 award as one of the fastest growing privately held companies in America.
More than $900,000 saved with a Medical Bill Review
EthiCare was referred an inpatient hospital claim of nearly $2,700,000 by an MGU that was handling a stop-loss claim on behalf of a stop-loss carrier. The claim was for a premature infant with numerous severe conditions. The high-dollar claim was processed by the TPA and paid by the Plan with a sizable PPO discount of 45% off of billed charges, creating an allowed amount of “only” $1,500,000. However, the claim was not audited by the administrator to determine if the actual billing and coding of the claim was appropriate. EthiCare performed a Medical Bill Review (“MBR”) Audit on the claim in question and uncovered $934,000 in billing and coding issues. It should be noted that EthiCare’s fee for performing the MBR Audit was only $5,000. In other words, the net savings potential in this case was $929,000.
EthiCarePrior-Authorization service helps plan obtain a 63% discount
A pro-active TPA and Employer Group implemented the EthiCare prior dialysis authorization service as a way to protect the employer group from steep dialysis charges by adding a plan amendment and EthiCare’s prior-authorization phone number to the back of their benefit card. EthiCare Advisors received a prior-authorization call from a large dialysis provider before the group’s patient started dialysis treatment. EthiCare worked with the TPA and the provider to obtain a discount that will translate into savings of more than $500,000 for the year. The all-inclusive settlement along with a signed release from the provider ensures no patient liability above their standard co-insurance and it also protects the group from future price increases.
EthiCare Saves Employer group more than $750,000 in one year on Dialysis Claims
EthiCare Advisors, acting on an out-of-network referral from a pro-active MGU, was able to ink a settlement agreement with an out-of-network dialysis provider. The provider originally wanted the group to utilize a weak wrap network discount they were eligible to access, but EthiCare was able to settle with the provider at a much more reasonable rate. The bottom line, our negotiated settlement saved the group from utilizing the inferior wrap network discount, saving our client an additional $500,000 over 12 months.
A Patient’s Question leads to $180,000 in Savings
A 67-year-old male patient with Hodgkin’s Lymphoma questioned the cost of the radiation therapy he was receiving. As a result, EthiCare Advisors, Inc. was contacted by the TPA to review the claims that charged the plan $75,000 per treatment. Team EthiCare reviewed the case and presented the cost saving options to the client. EthiCare was able to negotiate a 40% discount per treatment, resulting in a $30,000 savings for each treatment the patient would receive. This case has the potential to save our client a minimum of $180,000 this year.
Over $77,000 saved on Surgeon Bills
EthiCare received a claim referral from a client that included two claims. One medical bill was a surgery claim and the other was the corresponding assistant surgery claim, both from a neurosurgery group. The surgeon and the assistant surgeon each charged $49,954.32 for their services amounting to a total of $99,908.64. EthiCare successfully negotiated a settlement with the provider, obtaining a settlement of $19,000 for the surgeon’s claim and $3,800 for the assistant surgeon’s claim, for a total amount of $22,800. This resulted in a collective savings to our client of $77,108.64 or 77% of billed charges.
EthiCare Negotiated a 56% discount on a Surgery Center Claim
EthiCare received a $34,500 facility claim from a client. The claim was from an ambulatory surgery center in New Jersey. EthiCare was able to negotiate a settlement on the claim, obtaining a signed agreement that reduced the billed charges to only $15,000. This equated to a discount of over 56% off of the original billed charges, resulting in total savings on the claim of $19,500.
Nearly $85,000 saved on Surgery Center Claims
An EthiCare client asked us to negotiate a settlement on multiple ambulatory surgery center facility claims for a patient receiving numerous vertebral facet joint injections at many different levels (i.e., cervical, thoracic and lumbar vertebral levels). The billed charges for all claims totaled $141,400, for dates of services that spanned over 9 months. EthiCare successfully negotiated a discount of 60% off all billed charges; reducing the collective allowable amount on the claims to only $56,560. EthiCare saved the client $84,840.
U&C Recommendation Saves over $600,000
EthiCare received a hospital claim from a client that totaled $971,033.05. After a detailed U&C evaluation, EthiCare determined the U&C amount for the hospital confinement was $346,367.07, taking into consideration the patient’s diagnoses, procedures rendered during the confinement, length of stay, geographic area where services were rendered and the patient’s age and gender. The U&C amount represents a difference of $624,665.98 from billed charges. Subsequently, the client received several appeals from the provider. EthiCare assisted with all the appeal responses; as a result of the continued assistance, the original decision to apply U&C to the claim was upheld and the savings were maintained.
MGU saved over $200,000 using EthiCare’s U&C Service
One of EthiCare’s MGU clients asked us to review a patient’s nearly 4 month long high-cost drug treatment that totaled $821,673.00. The provider was in-network with a corresponding discount of 48% off of billed charges. The allowable amount was “only” $427,269.96 after the PPO discount was applied. On the surface, that appeared to be a “good deal” for the payer; however, after a thorough review of the claims and the services rendered, EthiCare determined the total U&C amount for the claims was $225,388.10. As a result, the provider received nearly twice the U&C amount for the services rendered in its geographic area when the first-dollar claims were adjudicated by the TPA on behalf of the health benefit plan. EthiCare’s MGU client opted to apply U&C to the claims since the applicable stop-loss policy contained terms and provisions that supported the application of U&C during the claim adjudication process. In the end, our MGU client saved $201,881.86 on the applicable stop-loss claim by utilizing EthiCare’s U&C services.
Paul E. Hacker, Director, Client Services
(888) 838-4422 Extension 713