A MATRIX Minute by MATRIX Group Benefits, LLC
And the charges just keep coming. What type of situation racked up $9,000,000 in charges and is continuing to? A burn victim? No. A multiple organ transplant with complications? No. Prematurity with complications? No. Neurotrauma? No. Gene therapy? No. The answer is COVID-19 – an extreme long-haul case.
After 145 days of inpatient stays in 3 hospitals in two cities, medical air and ground transportation, too many physicians to count, ventilation, ECMO, EUA drugs, and then discharge to a LTC facility, all the providers are seeking payment. And all are out of network and no negotiations or agreements were pursued at the beginning of a transfer and new inpatient stay. In fact, all procedures for pre-cert or prior authorization, concurrent review, and medical case management were missed because no one was reporting the patient after the first discharge for the transfer to the second facility. Why all the transfers? Shortage of supplies and equipment, and no one (reportedly) tried to secure needed equipment and instead transferred the patient from facility to facility without regard to any insurance or benefit plan considerations or requirements.
When was this situation reported? The first knowledge of this situation occurred when the third facility submitted an interim bill for over $5,000,000. Up to this time the extended hospital stay was not known.
What would your self-funded plan do in this type of situation? Do you have the right resources available? Would you be able to navigate the impact of this type of claim with the terms of your coverage and the timing of your next renewal? Understanding how medical stop loss coverage works, what the terms of coverage and claim basis mean, and how claims impact underwriting and renewal considerations are important aspects of being the fiduciary for the self-funded plan.
Matrix RMS worked with the employer and claim administrator to develop a plan for negotiating the facility charges, and then RMS engaged the insurer and reinsurer to get their concurrence with the plan. RMS then engaged a specialized bill review firm to analyze the itemized bill for coding and charges and assess them for R & C pricing comparison and a Medicare allowable comparison. RMS also engaged a consulting firm that specializes in provider bill negotiation to work with the claim administrator in the negotiation of the facility charges. The negotiating position was strengthened by the well crafted language in the plan document regarding adjudication of charges from out of network providers. Both engagements were arranged on a fixed fee basis.
After almost three months from the time the first interim bill was identified, what started out as a demand for payment based on billed charges, morphed through multiple versions of discounts off billed charges, to greater discounts or a similar payment amount using a percentage of Medicare, to finally an agreement for payment based on 135% of Medicare. Throughout the process, the facility position was a percentage discount off billed charges without an audit and the plan’s position was to require a complete itemized statement before discussing possible payment terms using a percentage of Medicare. Throughout the process, the use of the facility’s own operational and financial statistics and metrics provided the information needed to refute negotiation positions the facilities presented.
In the end, the efforts lead by RMS resulted in facility claim savings of $6,900,000.
Inviktus 