U.S. MEDICAL BENEFITS - COST MANAGEMENT

Item # MBCM1 – Transparent Cost-Plus Hospital Pricing Engine to Eliminate the Difference Between what BUCAH’s Charge to Benefit Plan vs. Bill the Hospitals                                  

This Vendor Re-prices each Hospital Claim on a Cost-Plus Basis so as to minimize the Difference Between what the Carrier’s / TPA’s Charge to the Benefit Plan on a Billed-Charges-Minus Basis and the Amount they Actually Settle for with the Hospital under Negotiated Provider Contract Pricing. Savings Range from Between 20% and 40% over Typical BUCAH PPO Charges

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Item # MBCM2 - No Access Fee, Stand Alone or Companion Diagnostic Imaging Specialty PPO with 50% Claims Cost Savings Potential  

This actively-managed nationwide, radiology network was established 10+ years ago to better manage the cost and service of highly utilized and expensive diagnostic procedures such as MRIs, CTs and P.E.T. scans. A scheduling concierge service with a combined experience of managing over 250,000 diagnostic claims ensures efficiency, accuracy, convenience and a positive patient experience. Patients are  directed to fully- credentialed, quality guaranteed, typically free-standing (hence low cost) imaging facilities at greatly reduced rates with savings passed on to the benefit plan. The program is 100% free to implement and utilize as there are no pepm’s, no percentage of savings fees, no implementation fees and no per bill fees. Average diagnostic test savings equal 30% per procedure over traditional PPO discounts

 

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Item # MBCM3 – New Style, Actuarially-Derived Flex Plan Design to Decrease Both Employer and Employee Taxes Further Than Old Style, Traditional Flex                                            

An Independent Actuary has developed a Process under which Various Provisions in the Internal Revenue Code can be combined to Allow for an Actuarially-Derived Tabular Value to be used as the Basis for Establishing the Employees Pre-Tax Contribution Amounts. This Further Increases Employees’ Pre-Tax Premium Deductions thereby Increasing Employees’ Take Home Pay and Deceasing Employer Payroll Taxes both beyond the Traditonal Flex Parameters

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Item # MBCM4 – Contingency-Fee-Based, Kidney Dialysis Cost Containment and Claims Settlement Service       

More than 25 million Americans have chronic kidney disease and the annual cost for a single patient’s dialysis treatment can exceed $500,000. This consultancy develops a different plan of attack for each dialysis patient in order to achieve the most successful settlement. Proven solutions to limit rising costs include pre-authorization, Usual & Customary reduction recommendations, unique out-of-network steerage solutions and negotiated settlements. Services are provided on a contingency fee basis. A free initial analysis of current outstanding claims is available in order to estimate the employer’s savings opportunity. This cost containment service has an average savings of $20,553 or 75.1% per claim.

 

Item# MBCM5 - Carrier / TPA Independent, Contingency-Fee-Based Cost Containment and Negotiated Settlement Service for Oncology Claims  

 

1% of covered plan members may already have or may have been diagnosed with cancer at any given time; which may account for more than 15% of total plan costs. This service provider helps plan sponsors manage all types of cancer-related medical claims for in-patient admissions, out-patient and infusion center treatments, physician charges and pharmaceutical claims. Experienced specialists such as registered pharmacists, RN’s and certified coders work as a team to implement various cost savings models suited to the needs of each individual client. Models can include tactics such as a pre-authorization program, fair and appropriate UCR re-pricing with appeal support, Medicare Plus re-pricing and negotiated settlement agreements. Services are contingency fee based with a success rate of settling in-network claims for an additional discount below the PPO 60% of the time. Average Savings = $5,650 or 24.6%, per claim

 

 

 

Item # MBCM6 – Physician-Led and Location-Specific Quality-Driven Healthcare Plan Cost Reduction Process                      

This is a Seven years-in-the Development Quality (and Cost) Improvement Process that Includes an Assessment of the Current State of Quality of Care Locally followed by the Deployment of a Cost/Quality Advisory Committees Consisting of Physicians, Finance, Labor/Management, etc. and the Implementation of Joint Patient/Nurse Local Community Condition Management and Accountability Platform plus Integrated and Revised Benefit Plan Design. ROI measured in Terms of Decreased Trend and /or Spend by Location  

Item # MBCM7 - Contingency-Fee-Based Healthcare Plan Audit to Recover ERISA Plan Assets Recouped by the ASO but Not Returned to the Benefit Plan

Via their Annual Internal Business Audits, Insurance Carriers, TPA’s and ASO’s often find they have “Overpaid” Health Care Providers. Yet such “Overcharges” are subsequently collected, seldom make their Way Back to the Health Plan as a Legally Required Restoration of ERISA Plan Assets. This Contingency Fee-Based Auditing Firm conducts a Specialized “Recoupment Assessment” Going Back up to 8 Years so as to collect the Overpayments for the Plan which typically Range from 3-7% of Total Claims

Item # MBCM8 - Contingency Fee-Based, Healthcare Claim Coding Error Assessment & Subsequent Recovery of ERISA Plan Assets                                                                                           

Healthcare Plan Claims Processors make Millions of Dollars (%2 - 7% of Total Plan Costs) Worth of Coding Errors and Overpayments each Year. Their Automated Claims Adjudication Systems contain Only a Limited Number of Coding Edits (and 15% of All Claims are Manually Adjudicated). Moreover, these Edits Require Frequent Updates many of which are not made, for the Continuously-Changing Set of Over 20 Million CMS-Derived and Correct Coding Standard Edits. This Plan Auditing Firm Reprocesses up to 3 Years of Back Claims and Checks Each Claim againstMillions of the Most Relevant Coding Edits as such Edits are not checked within the Traditional Plan Audit. Auditor achieves a 55% Average Recovery Rate for Found Errors within a 40% to 70% Range. Mis-Payments Need Not be collected from Plan participants

Item # MBCM9 – Insourced Healthcare Plan (And Optionally, Rx and Dental) Claims Audit Tool for Continuous Internal Use by the Employer                                                                                       

Errors such as duplicate payments, lack of medical necessity, missed third party liability, unbundling, upcoding, out-of-network, reasonable and customary non-compliance, modifier abuse, payment of excluded services, payments above limits, etc. are still all too common.  This proprietary, intelligent and highly selective auditing software allows employers to audit their own healthcare claims against their benefit plan language. It covers over 90 categories of pre-defined medical claims concerns and includes licensed and imbedded industry standard medical codes (e.g. CPTs, ICD-9s, and others).  A robust reporting engine includes many pre-defined reports that can render easily in PDF or Excel.  With industry healthcare claim errors typically in the range of 1 – 3 % of paid claims, this software can result in a significant ROI – anywhere from 1X to 5X. 

Item # MBCM10 – Insourced Healthcare Plan Dependent Eligibility Audit Tool for Continuous Internal Use by Employer

Despite the new healthcare law, systematizing an ongoing process to ferret out ineligible participants as they occur makes sense. This proprietary software tool is used internally by the employer to conduct audits from start to finish. Functionality includes importing data, fixing it if necessary and verifying that data is correct and without inconsistencies. The system contains 50+ separate verification checks just to get the data ready for audit and it provides a complete set of forms and reports that get auto-filled and managed throughout the audit cycle.  The Ssoftware is highly customizable and can accommodate any plan language provisions.  Various management and tracking reports are available, in PDF or Excel, in real-time.

Item # HBCM11 - Contingent Fee-Based, Audit and Negotiation of Appropriateness of In/Out Patient Facilities Bills In Lieu of or In Addition to, a Traditional Accuracy Style Bill Review (U.S. Only)                        

Traditional facilities bill review services typically evaluate only the accuuracy of the coding and not the appropriate Amount of the charges. This service deploys proprietary heuristic software that reformats the data on the itemized bill to enable medical doctors and compliance specialists to identify and remove erroneous charges. The platform works from a ‘Benchmarking and Proper Coding’ perspective that includes the hospital’s chargemaster procedure costs, federal data and other parameters so as to also focus on what is  fair and reasonable pricing for every item / service - not just the accuracy of the billed charge itself. Asssigned analysts suppoted by ERISA attorneys secure post-audit signed agreements from providers before the employer / ASO provider is presented with the newly reduced bill for payment so as to virtually eliminate any balance illing, reconsiderations or possible litigation. There isa 95%+ success rate with a 32% average savings

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Item # HBMC12 – Single Premium Annuity Funding of Retiree Healthcare Benefits to Transfer Risks to Insurance Company and Create Financial Statement Advantages (U.S. Only)           

Having to maintain post-employment healthcare benefit plans can be risky and more expensive than necessary. One alternative is to redesign and fully-fund retiree medical liabilities for all or a  segregated group of retirees. The funding can be accomplished by purchasing a group annuity contract from a top-rated insurance company and per the Wells-Fargo Court Case (See your Tax Advisors) receive a full current income tax deduction and immediately remove / reduce the balance sheet liability for affected portions of the retiree population. This approach also shifts future mortality and investment risks to the insurance company

 Item # HBCM13 - Neonatal Intensive Care Unit (NICU) Physician-Led Consulting and Cost Management Services

The number of pre-term births is steadily rising and many health plans and facilities lack the knowledge and resources to efficiently manage the related medical complexities. This 12+ year old Neonatologist-guided consultancy works directly with treating physicians to both assess and collaborate so as to offer the best evidence-based care for medically complex infants. They also provide individualized support for the affected families both pre and post NICU discharge. The results are positive effects for both clinical and financial outcomes

Item # MBCM14 - Online Walk-In Clinic Locator to Support Efficient Use of Health Care Resources

Employees who need routine, non-emergency health treatment frequently use expensive hospital emergency departments because in most communities, nearby hospitals are generally easy to find and require no appointment. Less expensive walk-in / retail clinics cost much less but can be difficult to locate. This online locator provides access to 2,500+ US walk-in /retail clinic locations located within a 5-50 mile radius of any city, town or zip code. The web-based, smartphone-friendly locator can be easily linked to an employer's HR / healthcare benefits portal. By using this tool, employers can save hundreds of dollars per visit on employees' routine, non-emergency care.

 

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Item # MBCM15 - Comprehensive, Yet Competitively Priced “Secondary Insurance’ to Help Employees Pay for High Deductible / Out-of-Pocket Healthcare Expenses

 

With traditional group health insurance premiums rising, both employers and employees are increasingly selecting high dollar deductible plan options thereby leaving employees exposed for paying first-dollar inpatient and outpatient healthcare expenses. This secondary insurance coverage fills that gap and can typically be purchased at premium rates that in combination are less expensive than if traditional first-dollar coverage had been purchased on a group basis instead to cover the same or even lesser expenses (e.g.  2 +2 =3). Coverage for facilities, surgery, physicians, etc. can be purchased for inpatient services in optional maximum amounts ranging from $500 to $10,000 and for out-patient services ranging from 40% to70% of the chosen inpatient maximum. This insurance plan can be paid for by the employer, employee or a combination and claims payments are settled between the secondary insurance carrier and the providers so as to eliminate the coordination burden from the employee. 

 

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Item# MBCM16 – Shifting Employee, Spouse & Dependent Coverage Claims Liability Risk to Healthcare Plan of the Spouse via IRC Section 106 to the Financial Advantage of both the Employer and the Employee

 

 Employee and dependent claims are the major determinant of the cost of the employer’s healthcare plan in general and also any subjection of the employer to the potential ACA Cadillac Tax . This service uses IRC Section 106 guidance to allow the employer to shift its employee and dependent healthcare claims and expense liabilities from the employer’s own plan (the home plan) to the plan of the employee’s spouse (the spousal plan) , if any. The employee wins as the employer typically reimburses the employee for both any excess employee premium contribution that the employee would incur under the spousal plan and 100% of the employee’s out-of-pocket costs.  The employer wins by shifting healthcare claims and expense liabilities from its home plan to the spousal plan thereby limiting the employer’s liability for shifted employees to an just the employee reimbursements for any excess employee premium contributions plus the desired  amount of employee out-of-pocket expense reimbursements the employer decides to pay for.

 

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Item # MBCM17 - Transferring High Dollar Claimants and Their Liabilities to the Individual Health Insurance Marketplace  

 

Typically, 2% / 4% of covered employees account for 50% of the employer’s total healthcare plan spend. Using proprietary and compliant tools and processes, this vendor induces such employees to move from the employer’s the group plan over an individual health insurance policy. The employer then reimburses the employee for all premiums and out-of-pocket expenses associated with the individual policy. The employer also reimburses the employee for the income tax effect as such reimbursements are generally felt to be taxable income to the employee. (Please seek professional tax advice.) The vendor handles all program administration and the fees charged to the employer are contingency-based. Reductions to the employer’s healthcare spend range between 18% and 32%.  

 

Item # MBCM18 - Using Medicare Secondary Payment Rules to Reduce Kidney Dialysis Charges Made against the Healthcare Benefit Plan

 

Providers of dialysis services can grossly over charge the benefit plan. This vendor has developed a process where under the employer’s benefit plan is formally amended to limit dialysis payments to 150% of the Medicare Allowable Charges. For the first three months of dialysis, the providers get reimbursed for amount in excess of the 150% limit from a tax-favored, employer-sponsored medical reimbursement plan or “MERP”. After 3 months, the patient becomes a Medicare Qualified Beneficiary (MQB).  At that time, Medicare Providers are still reimbursed at the 150% level and but are precluded from balance billing the MQB employee /dependent so that the employer makes no further reimbursements above the 150% level either from the benefit plan or from the MERP. The vendor handles all program administration and the fees charged to the employer are contingency-based. Reductions to the employer’s healthcare spend depend on the number of dialysis patients and their related expenses.   

 

Item# MBCM19 - “Medical Tourism” - High Quality, Low Price International Surgical PPO for Select Surgical Procedures

U.S.-performed surgeries come at a high cost in comparison to those same surgeries performed on a high quality basis outside the US. This 5+ years-in-the-development & refinement global surgical PPO consists of carefully selected, on-site screened, Joint Commission International accredited, highly US-affiliated hospitals that meet or exceed US standards. The assigned Case Manager and the PPO’s vastly-experienced US-based Chief Medical Officer interact with the patient to provide second opinion, select an appropriate facility, process forms, secure third opinions from U.S./British (or equivalently) trained and board certified international physicians and arrange travel logistics. Patient and chosen travel companion fly to destination, check into 4 star accommodation, meet with English-speaking surgical team, have surgery and engage in physical therapy before flying back to continue with any necessary further treatment with US-based providers. Fixed case rates include all travel and medical related expenses plus a personal accident and complications insurance policy. Savings range from 30% to 54% (41+% on average) and can be used in part to create various patient incentives with the balance of the savings be retained by the benefit plan.       

 

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Item# MBCM20 - Guide for Employers Moving from Fully-Insured to Self-Funded (but Still Insured) Healthcare Benefits

 

As the costs of fully-insured health insurance programs continue to rise and as the marketplace adjusts to ACA, the need for smaller employers’ (10 to 250 employees) and mid-sized employers (250+) to self-fund group health benefits and realize the advantages is more apparent. This Guide on self-funding identifies the risks involved, shows how to limit and fully-fund the risk and outlines the “newest” technologies, products, regulations and concepts in health care benefit program administration and management so as to reduce and / or avoid healthcare costs. Content examples include TPA vetting, ERISA benefit design flexibility, lowering premium taxes, navigating to self-funding, overviewing IRC Section 105 and 105(h), HRA custom document creation, SPD and stop loss insurance coordination, health care analytics & predictive modeling, solutions for pharmaceutical benefits management, description of wellness programs and more. Results allow the employer to enter into a self-funding arrangement with an understanding of the pros and cons and to have a program that exactly meets the employer’s

needs. 

 

Item# MBCM21 - Low Cost, Multiple Plan Sponsor, Pooled Risk, Health Ins

urance VEBA Trust with a Single Nationwide Premium Structure - Can also be Used for Franchisee and Associations Programs 

 

Organizations with experience-rated, fully-insured healthcare benefit plans or those with part-time or 1099 populations might want to consider pooling their risk with other employers / organizations under this plan so as to affect a cost savings. Under this non-union, multiple-plan-sponsor VRBA Trusted plan, 8 different plan designs are available and premiums remain consistent across all 50 states - regardless of where the employer is located. It’s available to any size employer with 15 or more employees, part timers or groups of 1099’s (20 or more hours per weeks) or less than 15 if there is an association or franchisee group. If claims history not available, employees /applicants must fill out medical /health questionnaires upon enrollment so as to keep premiums low and rate increases competitive. Program utilizes several major insurance carriers’ open access PPO networks.  Employer has no / $0 liability for any claims cost or run-out claims when terminating from the program. Premium billing, COBRA, employee communication, etc. handled by TPA 

 

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Item # MBCM22 – Individual Policy-Type Health Insurance Exchange that on Average is 33% Less Expensive than the Employer’s Own Group Plan and that Effectively Outsources the Employer’s Medical Benefits Program 

  

Group-type medical benefit plans have not been able to exclude employees with pre-existing conditions since HIPAA was passed in 1996. These provisions have caused the accumulation of excessively adverse risk pools for group plans / group insurers versus the individual policy insurers that have been subject to such provisions only as of 1-1-14. This timing differential has presented a reverse arbitrage and risk transfer opportunity for the employer between the two markets.   An individual insurance policy Health Insurance Exchange (HIX) was thusly developed to allow the employer to shift risk from the employer’s own group plan over to the HIX. Proprietary analytics allow the employer to measure the gross savings arising from the cost difference between the group plan and the HIX program while considering the income tax and ACA penalties. This savings has ranged between 20% and 60% (with a 33% average).  Employees benefit by having flexible costs and additional benefit choices. Employers benefit by transferring the healthcare risk to a third party, reducing the healthcare benefits  expense, switching from a defined benefit to defined contribution healthcare plan approach, plus eliminating both the annual / ongoing participant enrollment process and COBRA administration.       

 

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