security and automation in our system; an
experienced staff with appropriate levels of authority in what they are
able to adjudicate; and partnerships with specialty firms that maximize
cost control opportunities.
Regional Care saves its clients over $0.20 on each dollar in claims through our controls:
System Edits and Automation: Our
Group Benefit and Administration System (GBAS) has been designed to
automatically assign a specific benefit to each claim based on the
provider, place of service, procedure and diagnosis. This
automation leads to consistency and a higher level of accuracy.
Once the benefit is assigned several thousand edits are applied related
to the procedure vs. age and sex of the patient, the procedure vs.
diagnosis and the procedure vs. place of service. Any claim
triggering such an edit is reviewed by our most experienced staff and
our nurses.
Clinical Editing:
We have purchased sophisticated software to review provider billing
practices for strategies to earn additional revenue. Examples
include code unbundling, upcoding and pre-operative and post-operative
visits billed separately.
Out-of-Network Claims Management:
All claims received from providers that are not contracted with a PPO
are forwarded to a business partner in an effort to obtain a discount
through negotiation. Discounts are gained on over 80% of the
claims negotiated, with an average savings of 28%.
Subrogation:
All claims where there is potential of third-party liability are
researched to determine liability and agreement gained from the
participant that they will re-pay the Plan from proceeds of other
coverage. All claims with such agreement are tracked closely.
High Dollar Claim Review:
All claims with payments exceeding $25,000 are subject to physician
review, with the patient’s treatment notes compared to claims
detail to ensure the services provided and billing is
appropriate. If the physician identifies inappropriate charges
the bill is negotiated with the provider.
External Claims Audit:
We have retained the services of an independent audit firm to review a
stratified random sample of 3% of claims processed plus all claims
exceeding $15,000 prior to payment. Ongoing audit reports from
this firm are used to develop training programs and other quality
improvement activities.
Retrospective Surveillance:
Following adjudication all claims are forwarded to a business partner
that applies several editing programs for fraud and other issues.
This “last look” at claims is an additional level of
control that few TPAs have implemented.
Our clients are secure in knowing that we use every resource available to us so that the right amount is paid on every claim.
