In reviewing claims for a self-funded employer, we found that an employer paid $988,674 for an on-body injector. The contracted and posted rate for this procedure was $600. The employer overpaid nearly $1,000,000 for just this ONE claim. Employers have thousands to hundreds of thousands of claims per year.
Another example is when we analyzed a clients’ healthcare claims and determined a woman had 4 hysterectomies in one day. Now that’s a bionic uterus! All joking aside, this client paid $31,400 for this claim when they only should have paid the contracted and posted rate of $7,850. In this case, the TPA had their payment integrity edits turned on, but somehow missed this bionic uterus. Not only did they miss it, but they said for the mistakes they did find, they were going to charge 30% to correct them.
Why should the average person care? Who do you think ends up paying for these mistakes? The answer is: YOU!
The most unbelievable part of it all is that self-funded companies have been tricked into thinking this is normal practice. They’ve been so afraid of “healthcare” that reason and logic have completely evaded their contracts with these TPAs, i.e. TPAs charging 30% to correct their own mistakes.
Companies need to think about healthcare like every other line item in their budget. It can’t be the unknown or the overbilling and overpaying will continue. When CFOs ask me why their healthcare costs continue to rise, I suggest we start by looking at what they are actually paying. Not just the invoiced amount but what's actually being billed within their medical claims. Hidden fees and errors can account for 7%-12% plus in overbilling. One way to achieve Fiduciary oversight is to know what you are paying is accurate. Detailed claim reviews by companies that are independent from the TPAs should be a “must-have” in your toolbox.
4C Digital Health is committed to remaining independent from any real or perceived conflict of interest when serving our clients. Our team has vowed to act in the sole and exclusive benefit of self-funded employers.
This pledge to remain unconflicted is uncommon in the industry, but extremely important for us to deliver an unbiased perspective. In accordance to our commitment to clients, we hold the following as our guiding principles:
• Healthcare should be transparent
• Self-funded fiduciaries deserve unconflicted oversight
• The purchasers and recipients of healthcare should control the system
I invite you to fill out our short contact form. A member of our team will be in touch within 1 business day to get you started on your path to compliance and value.
Written By:
Megan Gaupp
SVP of Sales
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