Case Study #1
Claim Summary:
A PPO Member with Osteoporosis was referred to a laboratory for routine mammogram and preventative Dexa-scan by her physician. She received a bill from both the physician and the laboratory billing her over $800.
Remediation:
- Reviewed Explanation of Benefits and medical bills and concluded physician had coded the bill incorrectly and carrier had misadjudicated claims.
- Identified correct code. $400 was re-issued to providers.
- Plus lab charges billed to patient were overcharged.
- Compared contracted prices for procedure from other carriers in area.
- Submitted appeal to the lab with appropriate documentation to adjust overage charges.
Money Saved: $1,400
Case Study #2
Claim Summary:
An HSA Member with a chronic condition had an issue with prescription refill authorization. His medication was costing him $450/month.
Remediation:
- Obtained copy of member’s records and submitted documentation to carrier for urgent review on terms of medical necessity.
- Received approval from Medical Board and Medical Director
- Resubmitted all previous prescription claims
- Member met his deductible with submitted claim and received reimbursement
Money Saved: $5,400
Case Study #3
Claim Summary:
An HSA Member with a chronic condition had an issue with prescription refill authorization. Recent insurance changes through Employer, resulted in denial of medication. Member had a week of medication and, neither his HR dept. nor his physician were able to solve issue.
Remediation:
- Obtained copy of member’s records and submitted documentation to member’s IPA for urgent review on terms of medi- cal necessity
- Received approval from Medical Board and Medical Director in 3 days
- Located a pharmacy in area to fill prescription
- Member had refill 5 days after contacting us
