Claims cost is the top concern among employers and advisers in the United States when it comes to the price of healthcare. For too long, hospitals and other care providers have been submitting medical bills to insurers in one lump sum and employers are still writing the check without a second thought.

To drive down claims — which have reached anywhere from $900,000 to over $1 million — brokers are teaming up with medical management firms such as AIMM and Claim DOC to show employers exactly what they are paying for and who is performing these high cost medical procedures.

Beginning at a prequalified/pre-claim standpoint, Deborah Ault , founder and president of medical management firm Ault International Medical Management, works with employees who plan to have a medical procedure by researching and evaluating where the procedure is taking place, who is conducting it and how much the procedure will cost compared to other providers.

“Our focus is that the right patient is getting the right care, at the right time, are getting it at the right place and that it’s happening at the right price so that everybody in the situation wins,” Ault says. “We work predominately with self-funded major medical health plans or those who are looking to move into some sort of self-funding plan in the next 12 to 24 months.”

Until two years ago, Ault says she had no relationship with benefit brokers because either they had never heard of her services before or they would look for flaws within her business plan. However, after meeting with leading brokers such as Craig Lack and Nelson Griswold, with his nationwide Agency Growth Mastermind Network, Ault has finally begun to partner with brokers all over the United States to offer her services.

“We have partnered with just over 100 brokers, advisers and consultants across the entire U.S. who are interested in medical management,” says Ault, a registered nurse who is commonly known as “Nurse Deb” among her broker partners. “In terms of how many are actually doing medical management properly today — that are putting in place and leading the industry — I would say probably 20 or 25.”

Also see: Reducing clients’ health spend by taking an axe to claims

In order for the medical management model to work, every participant, from the broker down to the employee, must hold accountability for the health plans offered, the cost of procedures and the willingness to try a more affordable alternative.

Karen Gast, owner of benefits brokerage K2 Benefits in Peoria, Ill., says if a broker is not willing to put the effort into medical management, the program will never work.

“Some brokers just set up the model and then forget it, but if they are active with their clients and they are the point person for medical decisions, as an independent party, they can relay the information the employee needs to make an affordable and high quality of life decision,” Gast says.

After the claim

Sometimes the most affordable provider choice is not taken. This is where Ben Krambeck, CEO of Claim DOC comes into play. Krambeck’s team audit providers and facilitate claims while also providing litigation and defense for balance bills, handle appeals on behalf of the plan sponsor and directly contact with both providers and facilities where appropriate.

“Our broker partners use our team in a variety of ways,” Krambeck says. “We can assist in providing new vendor introductions, in sourcing stop loss for the benefit plan and work alongside our broker partners as an extension of their firm that they don’t have to pay for.”

Beginning his audits with a request for line item receipts for each individual cost for a procedure along with a copy of completed bloodwork for an employee, Krambeck has discovered major cost discrepancies among providers including overcharging on medical supplies and even gross medical negligence by care providers. One discrepancy resulted in the death and revival of a patient due to improper bloodwork prior to the operation. It was then billed to the employer as part of the claim cost.

“Why is the negligence of the hospital the employer-sponsored benefit plan’s responsibility?” Krambeck asks. But all too often, he says, “The TPA isn’t asking this question, the stop loss carrier isn’t asking that and the employer is not asking this question.”

Better outcomes have already begun to surface for broker clients utilizing medical management models. Gast says not only have her clients received savings on their annual medical claims, but for some employees it meant keeping all of their limbs attached.

“We had a member who was authorized by their primary care provider to have their foot amputated as part of a procedure,” Gast says. “After speaking with AIMM, we urged the employee to seek a second opinion from a well renowned provider rather than just the small town doctor.”

As a result of the second opinion, the member was able to keep their foot because of a proper diagnosis. “That’s not just dollars,” Gast exclaims. “That is quality of life for a person and I got to tell you, I like both of my feet.”

Register or login for access to this item and much more

All Employee Benefit Adviser content is archived after seven days.

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access