Categories

Most recent posts

  XML Feeds

Search

« As Hospital Costs Increase, Push Toward Outpatient Care Also GrowsCompanies Big & Small Welcoming Wellness »

Advanced Claims Surveillance Helps To Protect Against Questionable Billing

10/06/14

  09:38:00 pm, by MedBen5   , 457 words,  
Categories: News, Discounts, Health Plan Management

Advanced Claims Surveillance Helps To Protect Against Questionable Billing

operating room

The New York Times recently profiled the story of Peter Drier, a 37-year-old bank technology manager who underwent neck surgery for herniated disks last December. Mr. Drier had done his homework prior to the procedure, so he had a pretty good idea of the impending medical bills – save for one:

"He was blindsided [...] by a bill of about $117,000 from an 'assistant surgeon,' a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.

“'I thought I understood the risks,' Mr. Drier, who lives in New York City, said later. 'But this was just so wrong – I had no choice and no negotiating power.'”

The article mentions that much Mr. Drier’s insurer had negotiated the primary surgeon's fee to a much lower amount. But the out-of-network assistant surgeon was under no obligation to take a smaller payment. Ultimately, the insurer paid the entire $117,000 – though such costs invariably get filtered down to the customer through higher premiums.

Mr. Drier was a victim of what some medical experts call "drive-by doctoring," a practice in which high-priced assistants and consultants are brought in without the patient’s knowledge, and for questionable reasons. Although such arrangements are uncommon, their occurrences have grown of late – and underscore the need for heightened attention to the content of medical claims.

While an insurer or third party administrator can't – and rightfully shouldn’t – intervene with the delivery of care, it still has a responsibility to understand how that care is typically given, and to question deviations from it, no matter how minor. In MedBen's case, we use multiple methods of analyzing claims – and when necessary, acting on them.

For the majority of claims, MedBen’s in-house team – assisted by internally developed software that use 400 auto-checks to detect billing errors – handles claim processing from arrival to approval. But every claim, be it large or small, receives an additional level of scrutiny.

MedBen utilizes, at no cost to clients, an advanced surveillance system to look for instances of inappropriate billing in addition to opportunities for further cost reduction. When the surveillance system flags a claim, a panel of physician specialists further evaluates it to determine the appropriateness of charges.

Should a client receive a bill that appears to include a “drive-by,” our physician specialists will work with the patient, the doctor and the employer to arrive at a reasonable and equitable resolution. Often, such incidents can be settled for a fraction of the original bill.

Ensuring that clients pay only for the medical services they receive, and pay no more than what’s fair, is a critical component of health benefits management – and it’s a responsibility MedBen takes with the utmost seriousness. To learn more about our advanced claims processing solutions, contact Vice President of Sales & Marketing Brian Fargus at bfargus@medben.com.

No feedback yet