Claims Monitoring:

Actively Identifying Savings

2 CLAIMS

Identified and re-priced by Crumdale for higher discounts

$45K +

The amount originally requested from the group by the TPA

$42K+

Savings when in-network claims were correctly processed with only $3K due from the group, not $45K +

The Situation

MEDICAL CENTER

TEXAS

330 EMPLOYEES

One of our broker partners has a client that is a full-service medical center in Texas. The client was experiencing extreme increases in their medical claims spend without significant plan changes to merit the high costs.

The incumbent carrier program restricted the company’s ability to access medical claims information and failed to offer cost-savings solutions.

Due to the lack of transparency and poor medical claims management with their incumbent program, the company worked with their broker to switch to Crumdale Partners to transparently reduce costs through a proven claims monitoring process.

Goals

CLIENT:

Work with Crumdale to develop and implement an integrated claims management approach that identifies savings with vendor oversight.

BROKER:

Obtain transparency and cost containment for the client through Crumdale’s specialty claims management process and services.

The Results

IMMEDIATE RESULTS

With Crumdale’s active medical claims monitoring process and proven cost-containment solutions, we identified two claims for additional discounts and delivered the group $42,500 in savings.

Pricing

FAVORABLE DISCOUNTS, TERMS, AND CONDITIONS

Stability

DECREASE RENEWAL VOLATILITY

Control

ALLOWS FOR STRATEGIC PLANNING & FINANCING

How We Did It

THE CLIENT HAD MANY ISSUES WITH THEIR PREVIOUS PLAN AND CARRIER, WHICH CRUMDALE SOLVED BY IMPLEMENTING THE FOLLOWING:

Vendor Oversight

Claims Data Transparency

Active Claims Monitoring

Claims Review Process for Discounts

Expert Claims Negotiation

Cost-Containment Research

THROUGH OUR PROVEN CLAIMS MONITORING PROCESS AND COST CONTAINMENT, WE IDENTIFIED ADDITIONAL DISCOUNTS & CLAIMS ERRORS, PROVIDING SIGNIFICANT SAVINGS.

PROCESS

  • The Crumdale team actively monitored all claims to identify claims for additional review and/or cost-containment opportunities.
  • Two claims at the same facility totaling $49,000 in billed charges were scheduled to be paid with a 7% PPO discount.
  • Once the issues were identified, we notified the TPA and requested a second look into the claims processing.
  • We referenced the group’s prior claims data, suggesting this facility’s discount should have been significantly higher.

RESULTS

  • The TPA confirmed that the claims were processed incorrectly and took immediate steps to re-adjudicate the claims.
  • The claims were re-priced at only $3,000 instead of $45,500.
  • $42,500 in savings were delivered, and no other verified claims were affected.

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