Renal Claims Defense Solution
Solution:
$1,707,000
Defense:
$690,000
Specialty Care Management (SCM) Revitalizes Renal Care and Savings
In this case, a group had a member suffering from loss of kidney function. Historically, the member was using a provider, who was billing 6K/week for dialysis services, but the member moved to a different facility who was actually OON. This OON facility cost 26K/week. After the health plan received several large bills, they contacted their broker, seeking a better solution. The broker called Specialty Care Management, to see what they could do.
- Simplify the underwriting process
- Provide the plan with known liability
- Negotiate a steady $250K renewal rate
- Ensure no change in spec level
- Allow the patient to visit the provider of his choice
Taking on the case in the midst of the plan year, SCM utilized their Renal Claims Defense solution, which implemented a plan document language amendment for out-of-network claims and helped enroll the patient in Medicare Parts A&B. With these changes, SCM was able to underwrite the case rate of $250K, prorated for the balance of the year at $145K. This meant the group only had a liability of $145K for the remainder of the year and the member did not have to change their physicians.
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