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 Insurance Captive
Organizations with experience-rated, fully-insured healthcare benefit plans 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 captive insurance company program, 4 different plan designs are available to any size employer (certain high risk industries are ineligible) with 25 or more full-time employees (@ 25 or more hours per week). If a 3 year 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 a major insurance carriers’ open access PPO network and is fully-funded with "excess-loss" policies issued by an A++ rated insurance company. Good claims experience in the pool results in a return-of-premium dividend and the plan includes an administration performance guarantee with fees-at-risk.
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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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Item# MBCM23 - Cancer Care Benefit that Uses Evidence-Based Guidelines to Assure Most Efficient Use of Benefit Plan Dollars
Cancers typically represent the largest category of healthcare plan expenditures yet paid under the
major medical as all other services. In addition cancer is misdiagnosed or mis-staged about a third of the time and case-managed less than 50% of the time. To address these issues, this
cancer care services provider uses its own oncology experts and external national resources to help assure optimal treatment in coordination with patients, providers
and health plan administrators. Following verification of the diagnosis and staging, proprietary software containing the patient’s clinical facts and drug combination with pricing
references are used to identify the optimal evidence-based chemotherapy regimen / drug combination. Their resources allow 95% of patients to be treated locally. An available national
network of COE facilities is recommended only when found to be appropriate through diagnostic verification, evaluation/oversight and / or high patient volume
expertise. The cancer care benefit is specifically designed and PEPM-priced to meet each plan sponsor’s own objectives. Thereafter, the benefit is inserted into the employer’s legal Plan Document to
provide a much needed advocate-driven clinical pathway. Adherence to treatment guidelines has been shown to reduce cancer-related costs between 35% and 50%.
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Item# MBCM24 - Value-Based, Centers of Excellence Organ and Bone Marrow Transplant Management Program
Organ and bone marrow transplants are expensive to the benefit plan, and thus must be carefully managed. This 20+ years-in-the business, BUCAH-independent vendor uniquely combines outcomes management, timing optimization and net payable controls in order to reduce transplant costs. Performance modeling using risk adjusted transplant surgery data and outcomes metric analysis is used to identify and credential those centers operating at peak performance. This front-end credentialing work then allows for comprehensive provider contracting resulting in lower net payables for the benefit plan. There are no PEPM fees but the vendor does bill an access fee when a vendor contract has been utilized and savings to the benefit plan have been realized. Savings are in excess of 50% off national average costs
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Item# MBCM25 - Medical Benefit (i.e. J Code) Drug Management Services Provider
About 50% of employer’s specialty drug spend is billed through the medical benefit where operational, clinical and financial conflicts of medical carriers and /or PBM’s can interfere with producing optimal and cost-effective patient outcomes. Often, plan sponsors think the necessary management tools are in place to address “J” billing code usage or other selection criteria when in fact they are not. Thus, this services provider has developed an integrated process that streamlines workflows with all necessary and involved parties to optimize clinical and financial outcomes for self-insured plan sponsors. The process involves pro-active balanced coordination between a patient’s physician, an employer’s health plan administrator and a credentialed clinical team that renders evidenced-based coverage recommendations with an opportunity for peer level clinical consultations. The outcome for self-insured employers is greater visibility and transparency to actions that address increasingly complex high cost drug treatments in a cost-effective manner. . Expected ROI varies with a range of 1:1 to 8:1 depending on a variety of factors such as employer member demographics, disease mix and severity; and benefit design effect(s) on site of service and/or sourcing of drugs.
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Item# - MBCM26 -Surgery Optimization Service that Guides Plan Members to both High Quality Surgeons and Ambulatory Facilities Resulting in Lower All-in Surgery Costs
PPO plans limit physician and facility access and deliver multiple, poorly-linked provider bills. These bills arrive months later which can mask the cost of the total surgery itself, post-op infections and subsequent readmissions. This vendor instead, screens surgeons and Ambulatory Surgery Centers (ASC’s) via a proprietary vetting process and then concierge’s plan members to providers in their local area. Because of their patient -first design and rigorous patient care processes, ASC’s and attendant physicians conduct surgeries more efficiently and with less post-op infections thereby resulting in lower surgery costs. (1 in 25 patients contract a “Hospital Associated Infection” (per CDC), such infections have no PPO schedule and plan sponsors never receive reports itemizing infection costs.) All provider bills are bundled into a single, easy-to-understand bill and EOB allowing for the tracking of both all-in surgery costs and patient outcomes. Cost reductions have been $1.5 million per 1000 employees.
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