After the Claims are Paid

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. This case study addresses one of the latest developments in managed care—post-payment administration and claim recovery. Imagine the impact on your bottom line if you recovered 2 to 3 percent of claims, after all current internal processes were completed.

This service is available through Summit Re’s arrangement with Health Decisions, Inc., one of the most comprehensive and sophisticated post-payment administrators in the country. Independent benchmarking analyses have confirmed that its approach sets new standards for the use of data produced by claim payment, enrollment, and related systems. Through its services, you have access to postpayment support equivalent to that available to the largest payers— without development costs or lead time.

Potential recovery areas

The focus for recoveries occurs in the following areas:

  • Other liable parties not correctly reported by enrollees for benefit coordination
  • Medicare-as-primary payer (ESRD, retirees, disabled) to offset any Medicare-as secondary-payer demands
  • Enrollment discrepancies, such as ineligible and terminated members, family status changes, etc.
  • Provider billing errors, such as inappropriate service codes, unbundling, duplicate payments, discount avoidance, fee inflation, double billing, etc.
  • “Not a covered benefit” enforcement at the procedure code level
  • Judicial judgments, such as divorces, workers compensation, and subrogation

Services available

Existing data are combined with new data and converted to Microsoft® compatible files. This new data set has many applications, including supporting internal client management, maximizing claim recovery returns and processing efficiency, and supporting new client service offerings.

Claim Recovery Service

Identifies claims that should have been paid by others and pursues collection from other payers, such as Medicare or insurers, and providers.

Enrollment Support Service

Handles all the details of special (non-routine) employee/enrollee communications to compile, compare and reconcile internal and external data files across multiple payers.

Recovery Software

Use of Health Decisions, Inc.’s proprietary software on internal network systems.

Data Support Services

A full range of technical support permits translation of any documented file structure into Microsoft® compatible files for HIPAA compliant data analysis, reporting and warehousing.

Flexible payment arrangements

Health Decisions, Inc. can be compensated on a contingency basis, keeping 33% of recovered claim amounts. Health Decisions, Inc. is also willing to enter into a multiyear, fixed-fee software lease covering its Paperless Claim Recovery software suite and all related support services.

Client results

Client “A” used post-payment findings to pursue claim recovery and returned $15 per member per year to its bottom line.

Client “B” used post-payment findings as a continuous-quality improvement management tool to monitor internal performance improvements.

Client “C” used post-payment findings to pinpoint “problem” providers and to support provider contracting negotiations.

Health Decisions, Inc.

Health Decisions, Inc. is an established, reputable and successful post-payment administration and claim recovery vendor. In one yearalone, they processed almost two billion dollars of paid claims. In the area of claim recovery, nobody addresses more recovery areas (40+ review areas), offers a lower recovery threshold (all claims over $10) or recovers a greater amount of money per client (2-3 percent of claims).

Managing Capital Through Reinsurance

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. Summit Re works with London Life Reinsurance Company to provide reinsurance transactions that achieve risk-based capital (RBC) relief for qualified prospects.

Benefits

There are several potential benefits resulting from such reinsurance transactions:

  • Proper capital and surplus management can improve debt and claim paying ratings.
  • Reducing required capital requirements increases business line return on equity.
  • Dividend capacity can be improved for entities with holding company structures.
  • Individual plan or product line loss ratios can be stabilized for external understanding.
  • New business can be more competitively priced.

These programs can be developed for single-site organizations as well as regional and national chains. They can be designed easily for entities that have affiliated domestic or offshore companies. However, they also can work with a nonowned, protected-cell approach. All programs are structured to meet applicable risk-transfer regulations. Solutions are customized to meet each company’s specific objectives and requirements.

Case Study

Here’s an example of one of our clients' capital management programs developed through its relationship with Summit Re:

ABC Health Plan is a regional health plan. Its business is ceded to London Life via a 100% quota share above the HMO’s retention level. London Life, in turn, retrocedes the business on the same terms to a captive affiliate of ABC Health Plan. The transaction is designed to meet all regulatory requirements for full risk transfer and credit for reinsurance. In addition, the transaction has been disclosed to the insurance department of the state of domicile of ABC Health Plan.

Regulators often prefer or require independent professional reinsurers as the conduits for such transactions to minimize the potential for improper related-party transactions. The state insurance department in this case relied on the financial strength of the licensed and authorized professional reinsurer to fulfill its reinsurance obligations to ABC Health Plan. ABC Health Plan’s holding company is free to establish appropriate GAAP reserves and equity consistent with sound actuarial principles and subject to the reserve and capital requirements of the domicile of the captive.

Health RBC Relief Structure in Brief

The typical structure is modified coinsurance or coinsurance with funds withheld to minimize asset transfer. The only cash flow is your payment of the risk fee.

Reserves are held in asset trust by the reinsured.

There is parental guaranty on the retrocession treaty, if retrocession is used.

All profits, net of risk fee, are returned to you through an experience refund.

There is monthly accounting.

The health risk-based capital relief structure has the following risk reducing features:

  • Expense allowances set about equal to “marginal” expenses.
  • Losses to reinsurer are carried in loss carryforward and repaid through future profits. Ceding company must repay any losses if it terminates agreement early.
  • Loss to reinsurer usually limited by stop loss (typically 10% of premium).
  • Reinsurer can terminate agreement with minimum notice (usually 3 months).
  • Allows ceding company to release RBC requirement on business ceded.
  • Designed to pass required level of risk to reinsurer to meet risk transfer regulations.
  • Minimizes the cost of reinsurance to the ceding company (1% of premium or less).

Family Planning Rider

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. What do you do when your customers repeatedly request coverage which you are prevented from offering? This client turned to Summit Re for the solution.

The conflict

A large, regional HMO client had received repeated requests from its insured employer groups to provide coverage for family planning services. Because the health plan was owned by a Catholic hospital system, it was not able to accommodate these requests through its traditional HMO products. The health plan contacted Summit Re for assistance in solving this ongoing problem.

The resolution

Summit Re has a relationship with Advisors, LLC, a Michigan-based company that provides specialized group insurance consulting, product management, provider contracting, and network development services. Summit Re knew that Advisors, LLC had an arrangement with Unified Life Insurance Company (licensed in 45 states and the District of Columbia and rated B++ by A.M. Best) to provide independent, supplemental group insurance policies to selected Catholic-sponsored HMOs. Unified Life's Family Planning product and the Unified Life/HMO business arrangement are specifically designed to provide HMOs with an effective means to meet client demands for family planning services and still remain compliant with the ethical directives of the Catholic church and state insurance laws.

Flexible components

The flexible package of covered services operates with HMO, POS, or PPO plan designs. These services may be covered in any combination to meet individual employer group needs:

  • Artificial insemination services
  • Tubal ligations
  • Vasectomies
  • Pregnancy terminations
  • Oral contraceptives
  • Contraceptive devices

Direct administration

The Unified Life Family Planning product is issued directly to each employer group. As a consequence, the I.D. card of the Catholic sponsored HMO is not used at the pharmacy, claims for drugs and services are not the HMO's financial responsibility, provider services are provided through independent Unified Life provider contracts, and the HMO's filed certificate of coverage and rates can specifically exclude family planning services. Under the Unified Life approach, the HMO provides only limited cooperation by assisting the client with Unified Life set-up arrangements, providing monthly eligibility files and collecting premium. Often, the last service can be facilitated by a bank-trust arrangement.

All appropriate policies, benefit schedules, rates and forms are filed for each HMO arrangement with the state authorities by Unified Life. Each covered group is issued a Unified Life policy and all eligible members are given a benefit schedule and plan administrative information. Unified Life contracts independently of the HMO with a prescription benefit manager for contraceptive prescription services and medical providers for all other plan services.

Simple process

The Family Planning product operates very simply with no special actions required of employer groups and minimal member involvement. A brief summary of the product's operation follows:

  • At the point of group installation, the HMO transmits the eligible membership data to Unified Life.
  • Unified Life provides benefit notices to all covered members, which are delivered along with the HMO's standard member material. The benefit notice informs members of the benefit services available, the list of participating providers and Unified Life's toll-free telephone number to be used for all Family Planning benefit inquiries.
  • Covered members are encouraged to use Unified Life's network of participating providers for the delivery of covered services. If members use other providers, Unified Life will pay the provider up to the level of Unified Life's fee schedule. No referral from the primary care physician or plan service authorization is needed by the member.
  • Covered members using contraceptives for birth control purposes are given a special prescription drug ID card which operates like a standard ID card at the pharmacy, but only for contraceptives.
  • Medical service providers directly bill Unified Life and are typically paid within two weeks of receipt.
  • Unified Life delivers a group insurance policy to each employer group.
  • Unified Life receives monthly electronic eligibility updates from the HMO.
  • As a service to the employer group, the HMO collects a combined (HMO and Unified Life) premium from all covered groups and wire transfers the Family Planning product premium to Unified Life monthly. Some clients prefer to use their banks for premium receipt and dispersal functions.

Epilogue

Summit Re facilitated a meeting between the health plan and Advisors, LLC. The health plan and Advisors LLC worked out a plan that was specifically tailored for its marketplace. The program was implemented with ease and has been operating successfully.

Extend Your Product Line With Ancillary Benefits

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. Although our primary focus is protecting your company’s balance sheet through excess of loss reinsurance coverage, we also help you accomplish your strategic objectives with a broad array of other products and services.

This case study addresses adding ancillary benefits to your group medical plans, such as group term life, disability, dental and vision coverage. Summit Re provides these ancillary programs through Companion Life Insurance Company, rated A+ (superior) by A.M. Best. Companion Life offers competitive benefit programs which can be customized to fit your market needs.

Why Ancillary Benefits?

Most employers prefer the simplicity of one source for all their employee benefits, if possible. Agents appreciate the reduction in paperwork associated with working with one entity and are pleased when told that their ancillary sales through the health plan qualifies for the same bonuses as any other sale.

Customized Programs

Here are a few examples of ways the program can be customized:

  • Separate or combined billing
  • Propriety benefit and rate options
  • Proprietary brochure with your branding, e.g. logo, colors, typeface.
  • Flexible sales compensation, bonus and incentive trip options
  • Rating ability in your sales office

Companion Life has the experienced personnel to help you successfully market these products, including dedicated sales specialists in these product lines.

One Company’s Story

ABC Health Plan previously worked with a major HMO excess reinsurer with ancillary product capabilities in these product lines. However, the company was sold and service deteriorated. The new owner put less emphasis on ancillary products.

This health plan in the past was very successful at marketing these programs and had even assumed risk through a captive arrangement. Over time, they decided they prefer the non-risk approach where they’re strictly a distributor of the products and have no ongoing administrative role or underwriting risk.

As service issues persisted, they put their ancillary products out to bid. Summit Re assisted the client in development of the RFP, which was then used as a template to evaluate carrier bids. Companion Life’s bid included not only a formal response to the RFP, but also on-site presentations to personally address all product and service options, issues and concerns.

ABC Health Plan moved all of its ancillary product business (life, dental, and disability) to Companion Life Insurance Company. The relationship has “worked well” and ABC Health Plan is “very happy” with Companion Life.

Goal: Reduce Inpatient Admissions

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. You may be aware of Summit ReSources' consultative case management and managed care programs, but what you might not know is that our Managed Care Specialist is available to perform an in-depth assessment of your own medical management practices and procedures. This helps you ensure that your medical management is effective and efficient, not only for the benefit of your bottom line, but it also may ensure optimal outcomes for your members.

Goal: Reduce Admissions

ABC Health Plan recently contracted with Summit ReSources’ Managed Care Specialist to perform an evaluation of its medical management department. The overall goal of the health plan was to shift away from intense inpatient utilization management and focus on outpatient case management. In other words, the health plan recognized the importance of implementing steps to prevent the inpatient admissions in the first place.

On-site Evaluation

An on-site evaluation included staff interviews and assessments of policies, procedures, processes, and computer systems. Some of the issues addressed included:

  • Are the health plan’s policies and procedures consistent with the NCQA standards?
  • Are staffing patterns consistent with national benchmarks?
  • What is the most cost-effective way to perform utilization management?
  • What are appropriate outcome measures for medical management?
  • What key features should be included in a disease management program?
  • Which members should be referred for disease and case management?
  • What are appropriate measures for return on investment for disease management and case management?
  • What key features should be included in a predictive model?

Recommendations

Recommendations were made related to maintaining only the utilization management process that would provide the greatest clinical and financial value to the organization.

Since ABC Health Plan did not have a well-developed case management program, specific recommendations for the development of such a program were provided, including but not limited to, examples of case management referral triggers, screening tools, acuity measures, and return-on-investment documentation.

Post evaluation, there were several additional phone conferences regarding implementation of the recommendations.

The feedback from ABC Health Plan was that the assessment and recommendations were “crucial” and “most helpful” in moving the process forward to meet the overall goals of the organization.

Summit ReSources is available to provide an evaluation of your medical management program. Whether you are a small or large managed care organization, eliciting an outside evaluation of your medical management efforts can be beneficial. Summit Re works with efficient, cost-effective health plans, but most understand the need for continual improvements in medical management given the rapid changes in health care.

Managing NICU Costs

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. Neonatal intensive care unit (NICU) costs, especially for managed Medicaid populations, are one of the top drivers of overall healthcare costs for health plans. The major reasons for the high NICU costs are a significant variability in NICU care patterns, continuous advances in NICU care which is often reflected by higher cost of care, and longer lengths of stay as premature infants are born younger and surviving, albeit with more complex care needs. So what is a health plan to do?

Summit ReSources, the Summit Re managed care department, works closely with The Assist Group, an NICU management company that provides care management, forensic hospital bill audits and a new service called EvalAssist.

Situation: Increase in NICU costs premature births

One of our clients, ABC Health Plan, experienced a significant increase in NICU costs over the last 2 years without a corresponding increase in membership. Summit ReSources recommended that ABC Health Plan consider contracting with The Assist Group for EvalAssist. After an initial conversation with The Assist Group, ABC Health Plan decided to move forward with EvalAssist.

On-site assessment

The Assist Group provided an on-site assessment of ABC Health Plan's NICU medical management processes and staffing, NICU facility and professional contracts, and claims submission and payment processes. The Assist Group also provided care management services to several cases referred to The Assist Group by ABC Health Plan.

Over the course of several months, the staff of The Assist Group worked closely with ABC Health Plan to analyze claims data for the past two years and compare the billing patterns to the facility and provider contracts. The Assist Group neonatologists worked directly with the attending neonatologists to discuss the optimal treatment plans for cases referred to The Assist Group for care management oversight. The Assist Group also provided benchmark data regarding lengths of stay based on gestational age and birth weight.

Recommendations

After approximately 3 months, The Assist Group revisited ABC Health Plan to discuss the comprehensive assessment and provide recommendations to maintain or improve the NICU management while decreasing overall cost of care. The overall increase in cost that ABC Health Plan experienced over the last two years was determined to be related to several factors. The Assist Group identified each factor and made recommendations to improve financial outcomes while maintaining quality of care.

Changes

After the key factors for rising overall costs were identified, ABC Health Plan implemented the recommended changes. The Assist Group met with the attending neonatologists to discuss standards of NICU care, worked with ABC Health Plan’s provider contracting department to revise contracts as needed, and assisted the claims department in development of a forensic claims review process prior to payment of the claims.

NICU management has become costly and complex. If you are experiencing rising NICU costs and want to understand the reasons, it is sometimes cost effective to have an outside consultant, who is experienced in all aspects of NICU care, review your processes and possibly identify some factors that would make a difference in your bottom line.

Employer Stop Loss—can we really do that?

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. Offering your provider networks and care management programs to self-funded employers may be a key area of expansion and one that builds on your core competencies.

We have a long history of working with HMOs that contract with TPAs or establish their own ASO capabilities for the employer stop loss business. Our background in the managed care reinsurance market allows us to understand the challenges our clients face and present a wide array of solutions.

In fact, we are so committed to this effort, we explicitly mention providing employer stop loss products and services in our Founding Principles.

Range of services

In most instances, HMOs look to us for competitive stop loss quotes that reflect the savings associated with accessing their networks and care management programs. In some instances, however, HMOs have a properly licensed insurance company and are interested in becoming risk takers. They would like to offer employers a complete stop loss platform, including administration, provider networks, care management programs and stop loss coverage. Since most HMOs do not have the stop loss coverage expertise on staff, Summit is able to act as a managing underwriter—performing pricing, underwriting, policy issuance and claim functions.

Case study background

Company ABC is a very successful HMO operating in two locations. The company historically used a handful of stop loss carriers to offer specific and aggregate coverage to its self-funded groups. During one of our visits, we asked a simple question: “Why don’t you consider writing employer stop loss coverage through your insurance company, rather than somebody else’s?”

They called us back the next day and said, “Did you really mean it? Can we really do that?” We said yes, and the rest is history.

Taking control

This HMO moved the majority of its business from its previous carriers to the HMO’s insurance company. Company ABC staff members have the flexibility and control to meet marketplace conditions with respect to pricing and underwriting, including the setting of appropriate rates, lasers, and binding limits prior to the effective date of coverage. While Summit Re makes recommendations on pricing and underwriting guidelines, Company ABC ultimately decides what terms and conditions it chooses to offer employer groups, since the health plan’s insurance company affiliate is assuming the risk. Even though Summit Re does the actual underwriting, policy issuance and claims adjudication for this client, the client retains the authority to make all final decisions.

In addition to our day-to-day involvement with Company ABC, Summit Re lined up excess-of-loss protection for its employer stop loss portfolio after Company ABC absorbs a corridor of risk.

Results

The deal has worked out just as the HMO and its affiliates had envisioned: the marketplace reaction was favorable.

  • Clients knew the HMO had been in the marketplace for over 25 years and its B+ rating was more than acceptable (Weiss).
  • The HMO brought strong provider contracts and case management capabilities to the employer stop loss product.
  • The plan had good relationships with brokers, agents and customers in the marketplace.
  • It could now offer a fully branded product including its provider contracts and network management capabilities, its TPA services and its employer stop loss policy.

In the words of Company ABC, “Summit Re met all of my service requirements. Things are great from our perspective. We look forward to a long relationship with Summit Re on this product line.”

Although this client didn’t need it, Summit Re was available to provide sales and marketing training to HMOs who are new to this self-funded marketplace. Summit Re is also in a position to recommend consultants who assist HMOs in setting up their own administrative shops and in getting their stop loss policy forms and rates filed with departments of insurance.

This approach won’t fit everybody,but is it right for you?

Insights into large claims

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. An insight is the act or result of comprehending the inner nature of things or seeing intuitively (Webster’s dictionary). This is a good description of what takes place in a Summit Re InSight analysis.

We often have a better perspective for viewing this inner nature of a large claim, since we only deal with coverage for large claims. Your staff must spend a majority of their efforts in areas that involve smaller and much more frequent claim events. This case study is an example of how an InSight analysis conducted by Summit Re helped a plan gain a better view of the inner nature of its catastrophic claims.

Situation: An increase in large claims

ABC health plan, located in a large metropolitan area, focuses on Medicaid members, specifically AFDC/TANF eligible members. AFDC/TANF membership is primarily composed of mothers and their children, and the majority of the large claims for this population involve premature infants or other infants with significant problems at birth. For this reason, the large claims from these situations are primarily from inpatient hospital confinements at facilities equipped to treat infants who are severely premature or have other critical problems. ABC health plan was seeing an increase in large claims from this population.

Cause: Reimbursement structure

ABC health plan utilized strong DRG contracts for most facilities in its state. The exception to this was for facilities classified as children’s hospitals. These facilities were considered in a unique category by the state for its Medicaid reimbursement methodology, and the plan was simply following the state’s lead for reimbursement. These types of facilities were paid on a percentage of billed charges determined by the state.

The state’s intention was to recognize these facilities as unique, and the state therefore concluded that the DRG reimbursement was not appropriate given the level and type of services the children’s hospitals were providing. What that meant for ABC health plan was that its most severe and highest cost claims were often being reimbursed at a percentage of billed charges. In this instance, the plan had little ability to contractually modify this reimbursement, although that was certainly an option for the plan to explore.

The reinsurance implication

How did these circumstances translate to the health plan’s needs for catastrophic medical excess reinsurance coverage? The plan had been purchasing coverage with a relatively low average daily maximum limitation for inpatient hospital services because of a mistaken perception that the strong DRG reimbursements at many facilities and deep discounts at children’s facilities were protecting it from all risk except for the exceptionally long hospital stays. In reality, the facilities being reimbursed at a percentage of charges had been rapidly raising their rates and, despite the presence of deep discounts, the plan was experiencing average per-day charges on many large claims well in excess of its average daily maximum limitation for inpatient hospital services. This meant that the plan was absorbing a great deal of variability from large claims due to payments at very high costs per day.

Options

Now that the plan recognized the circumstances under which it was operating for many large claims, it could now consider the options for managing the risk. Re-contracting with children’s hospitals in its service area at more favorable terms would, of course, be a wonderful solution since it could be structured to significantly reduce the plan’s overall risk. In this instance, however, the plan was not in a position to implement such a provider contracting change. This course of action could certainly be considered in the future.

What could be restructured easily was the reinsurance coverage so that it would provide more coverage for high cost days. The best and most immediate solution for this plan was a higher average daily maximum limitation for inpatient hospital services, coupled with a slightly higher deductible. This allowed the plan to exchange reinsurance premium dollars for better reinsurance reimbursement for both long-stay and high cost-per-day hospital risk.

Although these changes may seem obvious to the party reviewing large claims day in and day out, they were not at all intuitive to the plan’s management staff, who had been spending a majority of their time and effort managing the everyday activities and finances of a health plan. It is, in fact, the purpose of the InSight analysis to bring these circumstances to the forefront when they otherwise would remain hidden in the day-to-day activities of the plan.

Case studies from The Assist Group

The Assist Group specializes in solutions for catastrophic claims management and high-risk premature infants. Current products include CareAssist, a unique, physician-driven neonatal care management program, and ClinAssist, a powerful forensic audit and claims resolution service. The Assist Group has a proven track record for delivering financial value to clients. For more information about these products and services, please visit the company's website, www.assistgroup.com, or contact Debbie Stubbs, RN, MS, CCM at Summit Re, 260-407-3979.

CareAssist Success Story: 32 % Reduction in Length of Stay and $163,693 Savings

This twin boy was born at 25 weeks, weighing one pound, eight ounces. His mother used multiple illicit drugs throughout her pregnancy and on the day of delivery. He was on mechanical ventilation and in critical condition when referred to CareAssist on day of life (DOL) 17. This infant was not expected to survive due to his prenatal history, the circumstances of his birth, and extreme prematurity. The CareAssist neonatologist recommended an ethics committee consultation to discuss quality of life issues when it became evident on DOL 30 that he would survive. By then, this infant had the severest form of intraventricular hemorrhage, along with hydrocephaly and porencephaly. He also had severe chronic lung disease (CLD) and remained on mechanical ventilation well past his first month of life. His long-term prognosis was poor.

His final discharge disposition further complicated his clinical status as his mother continued to struggle with polydrug abuse and was considered unsuitable to care for him after discharge. CareAssist consistently recommended early discharge planning to allow a foster family to be trained to care for this infant upon discharge. This timely intervention allowed this baby boy to be discharged appropriately and safely.

Multiple oxygen weaning recommendations were made by the CareAssist neonatologist. This infant was eventually weaned to nasal cannula oxygen on DOL 59 and was discharged on low flow nasal cannula oxygen. This infant’s nutritional status was complicated by his CLD and tendency to tire during feedings secondary to his compromised pulmonary status. The steroids used to help wean him from supplemental oxygen also compromised his ability to gain weight. The CareAssist neonatologist emphasized to the treating team the importance of using high calorie formula and advised early developmental interventions through the use of non-nutritive sucking and OT/PT involvement in nipple training. As a result of these interventions, the infant was nippling all of his feedings at a corrected age of just 35 weeks.

The weekly care oversight by CareAssist for nearly three months ensured consistency in the implementation of this infant’s treatment plan. Due to CareAssist’s oversight, this infant was discharged safely to foster care 39 days earlier than originally anticipated. This resulted in a 32% savings of $163,693.

ClinAssist Success Story: $321,757 Savings

A 110-day confinement at a children’s hospital resulted in total billed charges of $1,287,027. ClinAssist reviewed approximately 10,600 line items of detailed charges. Utilizing the clinical expertise of ClinAssist’s neonatologists and nurses, ClinAssist performed a forensic review of the charges and identified the following exceptions:

  • Room and board charges billed at incorrect levels of acuity
  • Experimental pharmaceutical therapies
  • Supplies and services incorrectly unbundled from the room and board charges

ClinAssist successfully achieved a $321,757 reduction in billed charges after the audit exceptions were presented to the facility. The account balance was adjusted to reflect the facility’s written agreement that the exceptions identified by ClinAssist were not payable charges.