Renal Re-Pricing Program, Now Enhanced by Renal Claim Defense

Specialty Care Management’s renal re-pricing solution manages dialysis claim cost through a predictable and quantifiable process, significantly reducing risk while protecting the patient and the plan from further financial responsibility. Since the product’s inception in 2002, clients have enjoyed an average savings of 84% off billed charges, with an impressive 100% discount retention rate.  SCM renal repricing works seamlessly with all Plans and operationally with any TPA or administrative entity processing claims.  Furthermore, SCM’s Renal Claim Defense (RCD) program completely eliminates the risk of and exposure to any legal and extraneous medical costs (outside actual, payable medical expenses) associated with SCM renal repricing. With RCD, the only expenses payable by SCM’s benefit plan clients are actual medical expenses, so defined by the benefit plan itself and applicable law.    

SCM supports the Plan Administrator’s fiduciary duty to prudently manage the Plan’s assets and administer the Plan in strict accordance with the terms of the applicable plan document. SCM provides an in-depth review and analysis of the Plan Document, as well as supplemental language tailored to the specific needs of each individual plan. The benefit is defined specifically, thus ensuring that the facility is unable to balance bill the patient. In addition, a registered nurse reviews claims to prevent clinical inaccuracies and inappropriate and inaccurate billing. Furthermore, the SCM program is suitable for both in and out-of-network providers, allowing the patient to remain with the doctors and nurses with which he/she is comfortable.

Unlike programs that limit the number of visits for which a dialysis recipient will enjoy coverage (thereby incentivizing providers to simply charge more per visit), the SCM methodology applies intricate definitions of Usual and Customary, as well as Reasonableness, to plan documents as it defines the Maximum Payable Amount in general, and as applicable to dialysis claim costs.  This creates a cap on covered charges, with anything exceeding said cap constituting an excluded charge. SCM establishes when Medicare functions as a secondary payer, to protect the Plan participant from balance billing, recognizing, and working within, the boundaries set by law.  Medicare entitlement begins in the fourth month of renal dialysis treatment; 42 U.S.C. §426-1(b)(1)(A).  This also marks the beginning of the 30-month coordination period where Medicare is a secondary payer.  This means that the group health plan is the primary payer for the first 33 months of dialysis.  In month 34, Medicare becomes primary and the Plan is secondary.

SCM’s renal re-repricing solution is reviewed on a regular basis by the leading industry legal firm specializing in benefits, health regulation and law. The SCM methodology and corresponding plan document amendment(s) apply a permissible, uniform limitation on all dialysis treatments, and thereby do not discriminate against individuals diagnosed with ESRD, per the requirements of the Medicare Secondary Payer Act. Additionally, all correspondence in support of the SCM methodology is thorough and reviewed by industry legal specialists.

The SCM process and response to pushback avoid confusing Federal requirements, Plan restrictions, and preferred provider organization (“PPO”) contractual provisions.

SCM’s fee includes the time consuming administrative burden of patient coordination, and claims administration, plan document review, consultation with SCM’S counsel and assistance with the crafting of each individual provider appeals at all stages. SCM also provides assistance with Patient application for Medicare Parts A & B. Claims are guaranteed to be returned to our clients, with a complete line item analysis of the discount, within 72 business hours. If, in the rare case, an appeal is litigated, SCM will support the appeal and provide consultation with its counsel at no charge. Our Renal Claim Defense program enhances this commitment by assuming complete financial responsibility for any legal challenges that may arise up to and including litigation.  To date, no provider challenge has been successful on appeal. In other words, SCM has never lost a provider appeal over the entire duration of providing this program. Our ongoing employment of outside legal counsel at no additional cost to our clients constitutes the most intensive review of legislative activity associated with dialysis, assuring the best financial results and most predictable plan costs.