Captive Group Dialysis Case
Specialty Care Management (SCM) Minimizes Risk While Maximizing Savings for Captive Group
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, 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.