Historically, self-insured employers have had little visibility into their healthcare spend and have been managing healthcare costs much like healthcare professionals utilize the standard level of care.
What does standard level of care mean? Also known as “best practice”, the standard level of care is treatment that is accepted as a proper treatment for a certain type of condition that is used by majority of healthcare professionals. As an example, in healthcare, if a patient has cancer, depending on the diagnosis, severity, etc., there are certain protocols followed to satisfy the standard level of care.
Self-insured employers have been coerced into this same approach when it comes to performance reviews on their carrier(s) and healthcare spend. A 250-350 yearly claims audit found within the contract between the self-insurer and the carrier is the only option self-insurers have to fulfill fiduciary responsibilities, make decisions around their healthcare spend, and ensure the overall proficiency of the carrier. The claim size for the audit is not only statistically irrelevant, but errors that are uncovered in the audit cannot be extrapolated over the remaining claims unless determined by the carrier. This does not allow the self-insured employer to fulfill fiduciary responsibilities to the plan, and provides no way of recovery for errors or overpayment made by the carrier.
What is Changing?
In the beginning of 2021, Congress passed the Consolidated Appropriations Act. Per cms.gov, “The Consolidated Appropriations Act, 2021 (CAA) established protections for consumers related to surprise billing and transparency in health care.” With this act in place, combined with various ERISA rulings, carriers can no longer refuse self-insured employers access to their healthcare data. Self-insured employers are now able to obtain a complete, comprehensive dataset to help fulfill their fiduciary responsibilities and drive decision-making.
4C Digital Health offers self-insured employers independent oversight of healthcare expenditures. 4C Digital Health excels in working with self-insured employers to obtain a complete and accurate data set from your carrier. In addition to obtaining your data, 4C Digital Health provides a robust healthcare data infrastructure with a complete suite of solutions that includes Data Supervision, Financial & Operational Controls, and Utilization & Spend Analysis.
Our services provide our clients with the information needed to drive decision-making through the use of our powerful analytical tools. Our clients gain unprecedented control and insight into their health plan that results in savings between 8% to 12% on their annual healthcare spend from a recovery and future cost savings perspective. The comprehensive data quality assessment performed, and the results from the Financial and Operational reviews of your healthcare spend allow employers to start obtaining answers to questions like:
Can I balance my healthcare spend to what was paid in the data?
Were the dollars paid to the carrier allocated properly?
Were my members' healthcare claims paid appropriately?
Are there overpayments due back to the plan that we did not receive?
How much am I paying in addition to administrative fees and medical claims? Was I aware that additional spend existed?
Does my Administrative Service Agreement and Summary Plan Description provide enough transparency and insight to allow me to budget and forecast appropriately?
4C Digital Health clients can access, view, manage, and make decisions utilizing 4C’s state of the art user interface, 4C Symphony. 4C Symphony is the ultimate data platform for health plan benefit administrators to implement and manage a digital strategy. The platform includes a comprehensive and fully integrated array of analytics, data management, and collaboration tools that empower you to reduce costs and improve outcomes.
Benefits is one of the largest spends within most organizations. This spend can now be managed just like every other expenditure in the business, from a financial and operational perspective with your collaboration with 4C Digital Health.