Case Study

Renal Claims Defense Solution

Renal Claims

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.

Are there millions in extra savings hidden in your health plan?

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