Meritain Health® - In the Booth

Understanding Out-of-Network Solutions

March 26, 2021 Meritain Health Season 2 Episode 9
Meritain Health® - In the Booth
Understanding Out-of-Network Solutions
Show Notes Transcript

•Meritain Health is always looking to bring industry-leading, OON solutions to the market. 
•Options give people flexibility to provide the best choices to help them meet plan goals. These are set together with consultants, and designed to meet risk preference.
•Every option has a balance between noise and savings, and that's for each individual customer to decide. 
•We can address high-dollar bill review in negotiations and audits through the processes we have in place. 

Welcome to another edition of In the Booth. My name is Bridgette Cassety, I am the head of broker engagement here at Meritain Health. I am so pleased to be joined today by someone that many of you have heard from before. He joined me and other in the booth sessions, and that is Dale Lyman. Dale is our head of network strategy, and cost-containment here at Meritain. It is always good to talk with him so our listeners can learn all about Dale's knowledge base, which in this particular session is going to be dedicated to out-of-network solutions. There is so much to cover in a short amount of time. I thought we would just go ahead and jump right into it for our listeners today. I thought we would start out with having you talk a little bit with us about how Meritain approaches out of network solutions. Can you sort of take us down that road?

 Yes, our principle guiding thoughts as we look at out-of-network solutions are really based on our total cost of care concept. Where we try to reduce the cost of the care, but at the same time improve the health of the patient. Then that way the group benefits and the member benefits, and it works very well in the out-of-network area because there are so many things that can be done. So many solutions that can be done to benefit both the member, and the group, and even the provider in many circumstances. It is a situation where we try to find the appropriate balance for the employer, member, and for the provider. What we ended up doing, because we do this, is we look at it from a very consultative position. We work very closely, with our employers, with the brokers, the consultants, to determine how we should approach the out-of-network solutions for each specific client.  When we do it that way what ends up happening is that we ended up having very customized and tailored solutions that meet the needs of the specific client. We look at how we can do things that will either impact the financial aspect of the group, if their needs are financial, if they have to reduce savings greatly. Or we can focus very heavily on making sure that the employee, or the member has the greatest opportunity to receive the greatest care. We look at it from a financial viewpoint, from a clinical viewpoint, but the important thing that I hope everybody can take away from today is that we will construct the program that best fits your needs. 

I think that you had a lot packed into that, certainly you talked about the win-win and being consultative with a customized solution. I think that what plan sponsors and consultants have on their minds when they hear that is great, but how does it translate into actual savings for our customers? Do you want to talk a little bit about the savings aspect of it?

Oh yeah, that is always the fun part because the savings we have achieved are industry leading, I don't say that lightly. We have been able to achieve, depending on which one of our programs you choose because there are multiple options we will talk about in a few minutes. We have achieved between 55% to 70% average savings per claim, that beats a lot of in-network discounts. Almost all those savings are savings in which we have an agreement with the provider that the member will not be balanced bill. That is a very critical part, especially on the higher dollar savings. On the higher dollar savings if there is a claim that is over $15,000, that's out-of-network, the average savings we achieve for that claim is 67% that's for $15,000 of those high dollar claims can really impact the bottom line. In almost all of those claims we are able to receive a signed agreement with the provider in which there is no balance billing. As far as the claims that we can capture. We are able to capture between 86% and 95% of the claims that come through that are out-of-network and on some of our programs close to a hundred percent. When you think about it, that means pretty much 9 out of 10, close to 10 out of 10, claims that go out-of-network we are now getting a discount. That discount is anywhere from 55% to 70%. That 55% to 70% even gets better when you look at claims above $15,000, because those are average savings is 67%. Last year alone, we saved our clients over $490 million in savings on their out-of-network claims. I would put those discounts, those percentages, the capture rate, up against anybody. It is truly an industry leading result.

Dale, what I love the most about talking with you is that those are phenomenal results that certainly benefit all the constituents that we serve here at Meritain Health. But what I always love is that you and your team are always looking to evolve that to make it better. Can you talk a little bit about how Meritain has evolved our out of network approach and bringing new products into that space? Because we are always looking to grow, no matter what the results are, we are always looking to make it better. Can you talk a little bit about that?

Yes. It has been a really fun journey to get to where we're at right now because this industry has evolved in so many ways. The needs of the groups have evolved in so many ways. We started out building the best program we could think of and bringing in basically every bell and whistle that we could put on to make sure that we were saving money for the clients, and for the members. And at the same time getting the maximum discount, but with the least impact possible upon the member. The industry has evolved to have many other what we call reference-based pricing programs, where you have a set fixed price such as a Medicare Like Repricing we call it. That is where you just processed the claim at a set figure, 120% of Medicare, which you take the Medicare price and you add 20% to it. Then you just reimburse, the out of network provider at that level. So we've had this evolution of our industry to be from employers who really want to not have any inconvenience or any concerns or issues with their employees, to those who they've got to be able to keep a plan intact, they have to reduce their expenses. They need to really focus on the finances. What we have done is, we have evolved to meet every one of those needs. If you're very concerned and your finances are such that you don't really want to put out your employees in any way, shape or form, but you still want to save money on the out-of-network and not pay outrageous prices. We can do that. If your financial objectives are such that you want to apply a fixed rate and only reimburse the fixed rate, we can do that. But what is critical about what we do is the core essence of everything we do revolves around auditing, clinical auditing, financial auditing. We make sure paying the bill correctly, and then looking at the market costs, for what it took the provider to do that and then negotiating. We're going to dive a little more into it, but that is the critical part of it. We are not just running claims through a bunch of different networks. We are not just applying a Medicare like Repricing. We are actually looking at specific claims, specific types of claims, specific dollar amounts of claims. And we are subjecting these to clinical and financial reviews and audits, and then we are negotiating whenever possible. That makes it different because that critical piece applies in every one of our programs. And that is what makes it so much better.

So, Dale, can you talk a little bit then around the different options and programs and solutions that we have now that using what you just talked about? Can you maybe just give us a brief description of each of those?

Absolutely. I mentioned the bells and whistles. This is the Lamborghini, our first offering, and this is the offering we have built over the years. It is the offering that most of our clients actually prefer. We just call it a Premium Offering. Basically, for the Premium Offering, we put everything we can on those claims. For the lower dollar claims, we run them through multiple how to network hierarchies. Meaning we try different ways to get claims on the lower dollar claims. Now, the interesting part about this is we base it on demographics. We look at where the individuals are located and say, “okay, which out-of-network hierarchy works for you best in that area? Where can we get the most money?” As far as I know, we are the only company that has multiple networks, based on demographics and location of the individual. That is critical because we do that in-network all the time. We say, “which network works best for you if you're in Kentucky? Which network works best for you if you're in California?” We do that on out-of-network too. So that is a major difference, but we also come in and we look at the claims and we are able to take a different route. If it is a dialysis claim, it's a cancer claim, high dollar drug claim. We actually route away from the hierarchy and we send it to our specialists. If it is a certain dollar threshold we do that. The first thing our specialists do is they would look at it from a clinical aspect and a financial aspect. Should this treatment have been done? Was it done correctly? Was it done in a way that is financially reasonable? So we audit, we look for codec changes. We look at everything on it and after we have got what we consider to be a correct claim, then we will negotiate based on industry standards and many other measures that we have. That is our premium program, very minimum member noise because there's agreement on almost everything. The next step we have we call the Enhanced. Basically, we took away some of those bells and whistles on the Enhanced. We do not run it through quite as many hierarchy things, but what we do is we still take a look at it. We still separate out the claims. We still base on diagnosis type of claim dollar threshold. We still look at those and we still run those through the bill review and negotiations. The difference though is on the lower dollar claims and then any higher dollar claims that we cannot get an agreement on. We actually run those through one level of a hierarchy. In other words, one out-of-network vendor. If that is not successful, then we run it through a cost to charge program, which is a Medicare like Repricing. The Cost to Charge program is where you look at what it costs the provider to provide a service, then we determine a payment based on that. So, what did it cost the doctor to do that service? And then we pay a reasonable amount based on that Medicare like Repricing. You take a Medicare like rate. On that one, you actually get a little bit more member noise, but your savings go up because you're actually sending more things through the Cost to Charge program and the Medicare like repricing. Now, the third and fourth options are for those clients who are more concerned about the finance. What those are, the first one, we call it our Cost to Charge a reference-based pricing. We look at what it costs the provider to perform the service, and then we determine an appropriate charge based on that. The high dollar claims with specialty claims, they still go through our bill review and negotiations. But if the bill review and negotiations is not successful, we send it to the Cost to Charge. If it's less than $15,000 and it goes straight to the Cost To Charge programs and you get that rating. So again, you say that the savings are greater, you get a little more member noise, but the savings are greater. The last option is that Medicare Like Repricing, where we are able to take an out of network claim. Again, if it is above $15,000, we send it to our bill review and negotiation, and they do all they can to clinically and financially audit it to get a successful acceptance of the claim.  If they are not successful, or if the claim is less than $15,000, it goes to our Medicare Like Repricing program. Again, increased savings but at the same time, more member noise because you are getting more claims that are going through what we call a fixed or mandated reimbursement rate. All four of these still include the bill review in negotiations, but they have different levels of savings, different levels of member noise and risks, but it depends on the group's needs.

 I think that that's a good point that you’re making, which is there's a lot of options, but the best option for each plan sponsor in conjunction with their consultant is really what are they looking to achieve? Right? We have all these different options, and which one is right for them is the one that is going to meet their goals and expectations for the plan. Would you agree with that?

Oh, absolutely. We will work with our groups to understand what their objectives are, and in a consultative fashion present them the different options based on their utilization. Based on what kind of claims they have and based on what they want to achieve. Then we can work with them and say, “okay, this fits more within like you’re thinking here or this it's more over here.” So we tailor it to the group's needs. 

That is great. Dale, as I said at the beginning when we started I knew that there was so much to cover and there's a lot of great information in there. I would like to summarize our conversation, this is a lot to summarize, but I guess if I were to take away a few things from our conversation here today, these are some of the things that come to mind. If I have missed something let me know. We want to let our plan sponsors and our consultants know that we are always looking to bring industry leading solutions out-of-network solutions to the market. What that means is that we are providing options. The options are designed to be price neutral, but to give people flexibility so that they can choose an option that achieves the goals that they have for their plan in consultation with their consultants, and to meet the risk preference, right? Because every, every option is going to have a balance between noise and savings. That's for each individual customer to decide. Is there anything else that I substantially missed? 

The only thing I would say, I agree with everything you just said. The last thing I would say is because of our high dollar bill review in negotiations, the audits, and processes that we have. When we add that to Medicare Like Repricing it becomes a much more profitable. Our discount averages go up, member noise goes down. A lot of people out there will say, “yeah, we'll put Medicare Like Repricing on a claim,” but they do not do the bill review and the negotiations like we do. So, they end up paying for claims they should not pay for. So, we are able to actually increase the savings and reduce member noise by including that in with our Medicare like Repricing. 

Excellent point. Thanks Dale. Well, I want to thank you again for coming and spending some time with me and to bring forth this information to our listeners on out-of-network solutions and how we're supporting our total cost of care messaging as advocates for healthier living here at Meritain Health. I want to thank our listeners for joining us today. We look forward to providing you with ongoing insights and important updates in the future. Thank you.