At USBenefits Insurance Services we take pride in our ability to identify potential claim issues to ensure the Plan is not paying for items that should not have been billed by the provider.
In our most recent example, the claimant was undergoing chemotherapy over many months, so we sent the initial claim to a vendor for an appropriateness of care and cost containment review. Upon review of the itemized bill, the vendor noticed that the provider was discarding a portion of the chemotherapy medication each time the claimant was receiving treatment. Obviously, the Plan should not be paying for medication the provider was not using on the patient.
While it may seem like identifying a small amount of a drug that is discarded would not add up to much in the long run, it did. After a review of all claims for this claimant, it was determined that the Plan was overcharged by $185,660! The vendor reached out to the provider and let them know that they should not be charging for discarded drugs.
The vendor then provided a detailed report documenting their findings and a line-by-line spreadsheet so the TPA would know exactly what items should be denied.
USBenefits handled all communication with the vendor so there was no additional work for the TPA. USBenefits also paid the vendor out of the savings, so there was no expense to the Plan. Your goal is our goal – to provide the best possible outcome for the employer.