The world of billing and coding of medical claims is far too manual and complex. The move to ICD-10 industry wide will continue to increase this. We believe this to be one of the largest drivers of healthcare cost. Claims payment systems, while sophisticated, can catch only a fraction of these errors. System edits focus on catching errors and fraud and abuse in professional claims, but facility based claims produce a different challenge. MBR provides a solution to this.
See the case study Beating Medical Trend – Managed Care vs Reference Based Pricing
Utilizing medical professionals, physicians and experienced coders, Continental Benefits reviews every claim in excess of $5,000 for fraud and abuse, miscoding, accuracy versus medical record, clinical appropriateness, and reasonability of charges. The audits influence not only the amount paid for medical claims, but the amount paid for stop loss insurance, as well as helps hospitals correct reoccurring billing errors. Audits are collaborative in nature with hospitals, and all produce results.
The unique position of an insurer as both the payer and the network contract holder lends itself to a less rigorous review of claims. Provider contracting can be a contentious process and claims audit findings can complicate these. As an independent TPA our sole purpose is to be the best stewards of our client’s healthcare dollar and we employ all resources available in this mission. It is important to realize that all audits and reductions to claim payments are made prior to payment to a provider.
Many Employers chase after networks with the largest discounts and discounts are important, but not the only thing. Continental Benefits uses the largest and best carrier discounts available, but the discount is only the starting point. After the discount is applied, on average we find another 6-10% additional claim savings cost for each in-network claim. For out-of-network claims, we reduce the claims an average of 67% off of billed charges. All clients that move to Continental Benefits experience much lower claim costs.