CUSTOM  HEALTHCARE SOLUTIONS

Dialysis 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.

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.

CLAIM   AUDIT   AND   NEGOTIATION

Deep Discounts
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.

  • Phase 1: Update The Plan Document to ensure the maximum savings
  • Phase 2: Enroll the patient in Medicare in order to start the ESRD clock and transfer the risk from The Plan to Medicare after 33 months.
  • Phase 3: Carve out the ESRD so that The Plan pays cost plus for services.

Pre-Payment Claims Audit and Review

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.