Case Study

Captive Group Dialysis Case

Specialty Care Management (SCM) Minimizes Risk While Maximizing Savings for Captive Group

SITUATION:
SCM was approached by a broker with concerns for one of his captive groups, which had an active dialysis case. Receiving a minimal network discount of 10% off billed charges, the group was met with provider charges totaling $631,000 on an annual basis with a spec level of $75,000. The group faced intimidation and pushback from the network, even though carve-outs were allowed.
CLIENT RESULTS:

By implementing the SCM dialysis cost containment program, the group saved $568,300 or 90% off billed charges, substantially better than the previous 10% network discount. And with SCM handling all provider appeals on behalf of the plan, an appeal was successfully denied at no cost to the plan.

SCM SOLUTION:

Step 1) The broker took initiative by aligning his group, an independent Third Party Administrator (TPA) and SCM and strongly influenced the network to work with a dialysis carve-out program. SCM, along with its strategic partner PHIA, reviewed the plan’s documents, made recommendations to further strengthen the plan language, and the plan was ultimately amended.

Step 2) Member ID cards were modified and the TPA issued new cards directing the provider to forward dialysis claims directly to the TPA for adjudication.

Step 3) A SCM Patient Advocate educated the patient on Medicare and its benefits related to ESRD and dialysis, answered clinical questions and helped the patient with applying for Medicare. The patient could continue seeing the provider of his choice.

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About Specialty CM:

We’ve designed a new way to manage catastrophic claims—one that brings costs back under control and delivers a complete risk solution. Plus, with double the savings compared to typical network discounts, we deliver maximized savings every time.
Exclusive Program Features:
No Set-Up Fee or Cost Until Utilization so you don’t pay until you have a claim
Medical Expense Protection safeguards you from extraneous medical expenses or legal fees
Flat Case Rate that protects you from inflation while saving you more off provider billed charges
Renal Claims Defense provides access to legal counsel and support for provider appeals while accepting fiduciary risk to eliminate exposure
100% Success Rate on challenges and appeals