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Carving Out a Costly Provider

06/17/18

  07:54:00 pm, by MedBen5   , 221 words,  
Categories: Cost savings, Third party administration, Claims management, Plan language

Carving Out a Costly Provider

knee x-ray

Plan language carve-outs don’t have to be limited to medical procedures or drug classes. If a provider grossly overcharges above reasonable and customary prices, then an employer can amend their plan to direct that the provider’s claims should be processed using separate criteria. And recently, a MedBen client who received an overinflated bill for knee replacement surgery did just that.

In Spring of 2017, a hospital billed a MedBen client $45,275 for a plan member who received a knee replacement, a fairly typical charge for the procedure. After network discounts were applied, the plan paid $26,217.

Several months later, the member’s other knee was replaced, but this time at an outpatient surgery center recommended by the doctor who performed the first replacement. The billed amount for the second procedure was $106,905 – well above the normal cost.

In response to the bill, MedBen advised the client to amend their plan language to carve out the outpatient surgery center from their provider network. Then, following a review of the claim, MedBen recommended that the plan pay $35,772 – substantially less than the billed amount, but more in line with the true value of the services received.

Effective use of plan language can make a significant difference in your health care costs, and MedBen can help. Contact Vice President of Sales & Marketing Brian Fargus at bfargus@medben.com to learn more.

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