Meritain Health® - In the Booth

TCOC: Payment Integrity

February 22, 2021 Meritain Health Season 2 Episode 4
Meritain Health® - In the Booth
TCOC: Payment Integrity
Show Notes Transcript

The value that Meritain Health provides for Payment Integrity.

Careful review of your claims and bills while maximizing discounts puts more money in your pocket. We’ll zero in on things like: 

  • High-dollar claims review. 
  • Hospital bill audit. 
  • Facility claim cost reduction. 
  • Out-of-network claim discounts 
  • Individual claim negotiations. 
  • Claims editing.  
  • Fraud, waste or abuse recognition. 
  • Subrogation recovery. 

Welcome. My name is Bridgette Cassety, I am in the broker engagement department here at Meritain Health.  I'm pleased to be joined today by Dan Day, who is our national head of sales for middle markets and Dale Lyman who is our head of network and cost management strategies here at Meritain. Today We're going to be talking about the value that Meritain health provides for payment integrity, which is one of the core components of our total cost of care approach. Dan, I thought I'd kick our conversation off with you today and just have you talk a little bit from your perspective about what payment integrity means to you and what you think are the key things that our listeners should be thinking about when they, when the topic of payment integrity comes up in the market.

At Meritain Health, our real drive is to lower the total cost of care.  We have four pillars that surround that cost avoidance, access, actionable data, and as you mentioned, payment integrity, which is a real key facet as to how that costs total cost of care is actually lowered. One of the reasons that we have such a high sense of payment integrity is we have a hospital bill audit function that is on our front end of the claim. This is also the reason why we have a lower than industry auto adjudication rate, much lower than all the national carriers, because we essentially slow that claim down, we look at the financial accuracy was the care appropriate with their clinical appropriateness, was the claimant and the member? Actually, Dale had this story that would highlight and illustrate how this comes to play.

Thanks Dan. We had a situation in which one of our members, Melanie, she gave birth to a premature baby. It resulted in 140 day in-patient stay the hospital bill is huge $9.1 million. The network allowed was 4.7. We got 55% off the bill right off the bat because it was an Aetna network member. Then we applied our hospital bill audit tool. We were able to remove another $508,000 off the claim or 12.5% additional savings. We did this by looking at the usage of nitric oxide. It was not following industry standards. We found anesthesia billed on days when there were not any procedures performed. My favorite, we found 31 hours of oxygen billed in a single day. We were able to, by going through the bill and reviewing it and applying these tools, save our client over half a million dollars.

Dale when you share that story, you talk about hospital claims, which are always big dollars that people can relate to. I am just curious if you can maybe share a little bit more with our listeners about how we apply those same kinds of tools and resources to other types of claims like maybe out of network?

Yeah. Thank you. I'd love to, it's so important because there is no silver bullet in this industry. What you have to do to achieve true total cost of care result is do all you can with a whole number of different tools. We take the same process that we used with the hospital auditing that we do, and we apply it across the board, especially to our out of network claims. We have a special team, that is our bill review and negotiations team. That is a good example of this. They come in and they will review every bill that comes through out of network that is a high dollar claim, or a special diagnosis, or a J code, certain types of drugs or procedures. They will review it to make sure it's accurate and then make sure it's clinical. As they do this, they are able to find a lot of errors. Then after they got an accurate bill, then they come back, and they will negotiate and they'll negotiate what we consider to be a reasonable charge. We have a lot of different tools. We use our algorithms to identify the claims, prepay, then we go in and we'll look at Medicare rates. We will look at the cost for the provider to perform the procedure. We will look at what they paid in the past. We have a number of different tools. A good example of how we apply these tools was we had a member named Hector. He was on his way home from work, a severe thunderstorm hit, his car went out of control, skidded off the road, and unfortunately it slammed into a utility pole. He ended up with a diaphragmatic hernia and had to have surgery. Everything worked out well with the surgery, but then he got the bill. The bill is $151,000, of which Hector had a significant amount. It was a financial hardship for him and for the group. We went in, we reviewed the claim, we got an accurate claim. We negotiated. Then we got a reduction of the charge by $123,000. Thus, eliminating a lot of the financial hardship for both Hector and the group. The important thing is when you are doing this is that you look at the whole picture, take a holistic approach and use data and human resources. You get eyes on those claims. That is why we have a little lower auto adjudication rate because we are having people look at the claim. In 2019, we saved our clients over $411 million. If a claim goes out of network with our system and what we do, 86% of the time, we get a discount. That is almost nine out of 10 claims. Our average discounts are 55%, those discounts are with the majority where there is no balance billing. The member is not harmed and not put at risk and the groups saves money.

Dale, I think that you bring up some great examples. The best part about having you on our podcast series is that you have very specific examples that show how we bring payment integrity alive here at Meritain. I think that it is great that we have an opportunity to show our listeners how we're practicing that. Dan, before we leave today, I thought it might be helpful if you shared with our listeners When you think about Meritain and you think about payment integrity as part of total cost of care, what do you think are the unique advantages that our listeners should really leave today's conversation with?

Well, at Meritain Health we take a very strategic approach to our cost management solutions and as spoken to before it is a very holistic approach. We have five main pieces to this. We have industry leading custom networks. We have a proactive review. We code at it. We audit claims on the front end, as Dale was explaining, we negotiate directly with providers, and we have teams that specialize in that we do a facility charge review every time.  We actually take a very clinical approach to things, to make sure things are appropriate and make sure that the member is properly cared for.

I think that you are right. I think the last thing that you said is one of the most important at Meritain Health we really pride ourselves on being advocates for healthier living. Whether it is through the stories that Dale shared or just our everyday approach, we are focused on enhancing member experience. When we enhance member experience, we certainly are also driving total cost of care down for our clients and plan sponsors. I want to thank both Dan and Dale for joining me today. I look forward to our listeners joining us for another series in our podcast around total cost of care. Thanks so much. You have a great day.