Case Study

Captive Group Dialysis Case

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

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.

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.


Step 1) The broker took initiative by aligning his group with the existing Third Party Administrator (TPA). Since SCM works with all provider networks, we implemented a dialysis carve-out program with the group’s PPO. SCM, and its legal team, reviewed the plan’s documents, made recommendations to further strengthen the plan language, and the plan was ultimately amended.

Step 2) An SCM’s Nurse Coach 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 was able to continue seeing the provider of his choice.

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