High dollar claims average between 50% and 80% of your plans overall claims costs. Health West’s team has been negotiating High Dollar Claims with hospitals, surgical centers and providers for over 20 years. We average 30% to 60% in hard dollar savings on these claims. We will work with you to set the dollar amount for audit and negotiation.
Catastrophic illnesses produce catastrophic claims, which are a major threat to any health plan. Our unique negotiating skills, medical knowledge and proprietary strategy mean big savings for your plan.
It is estimated that hospital billing errors result in overcharges of 26 percent. We are a leader in auditing and negotiating large and complex medical claims. Our specialty is claims exceeding $10,000.
We start with a detailed audit, look at pricing options and if warranted start our negotiation process.
Utilization and Pre-Authorization do not always authorize claims in accordance with covered and non-covered benefits and most times large claims go without a quality review for accuracy and appropriate billing.
High cost claims tend to be more error prone just due to the sheer volume of services provided. While these claims typically get closer scrutiny, they still have the highest potential for error and potential recovery. Health West offers a pre and post claim review to ensure proper claims payment compliance with your SPD and appropriate billing practices for high dollar claims.
Post-Payment Claims Audit and Review
Pre-payment claim review and audit is the ideal solution for catching problem claims up front like ESRD’s, Kidney transplants, ALS, LTACH’s and other potential high dollar services. Health West receives copies of all Pre-Authorizations, in-patient notifications and high dollar claims prior to claims payment. We pre-review the services for specific triggers and dollar amounts and notify the Administrators of potential problems, incorrect billing, SPD conflicts and high dollar claims, Claims are flagged for review, audit, negotiation and improper billing practices. This begins the
process of allowing the Plan to gain more control over their claim costs.
Pre-Payment Claims Audit and Review
Post-payment claim review and audit is the perfect for employers who want to look at claims that have already been paid to determine if the claim payments were made in accordance with their plan’s SPD and appropriate billing practices. Health West receives claims data/history and reviews all claims paid for compliance with the Plan’s SPD, standard claim processing practices and reviews claims over $10,000 or an amount determined by the Client. We also review Specific claims and other claims for errors and potential recovery of overpayments. We receive an updated claims data set each month for review and audit and work with the Administrator and providers to recover all over payments for the Plan.
Receive an average of 50% or better on out-of-network healthcare claims.
100% Provider Sign-off
We secure provider sign-off on 100% of negotiated claims to avoid post-negotiation disputes, in addition to producing lower healthcare costs.
$30 Billion in Paid Claim Data
Our database has over $30 billion in paid healthcare claims data, including typical reimbursements from national regional and local payors as well as Medicare, to help lower healthcare costs.
Advanced Benchmarking Analytics
Our proprietary database uses our Decision Data to determine what you should be paying for services rendered. This is where we negotiate from—not the billed charges in order to lower your healthcare costs.
20+ Years in Claims Negotiations
Our negotiators have more than 20 combined years in negotiation experience, including building provider networks and out-of-network fee negotiation.
Renal Dialysis claims are among the most expensive in all of healthcare. Even a single dialysis case has huge financial implications and can potentially bankrupt a Self - Funded Plan and detrimentally impact a stop loss carriers medical loss ratio. End State Renal Disease/ESRD has increased in incidence and severity over the last several years. According to the most recent data, over $500,000 was spent per patient for a course of dialysis treatment. While Medicare is traditionally the primary insurer after 33 months of treatment, there is discussion of increasing this to 42 months leaving The Plan with higher claim costs.
Health West assists the plan in auditing, negotiating and paying appropriate amounts for ESRD claims.
Dialysis Claims Audit and Review