Real Clients - Real Solutions

Success stories from our clients.

Success Story 1: Reducing emergency room utilization by investigating use.

During the first quarter claims review meeting with this employer (a healthcare provider with 600 employees), we discovered that the employees and dependents were utilizing the emergency room higher than the average benchmark number. The client’s usage of the ER was 8.50% of total claims, far exceeding the benchmark number of 1.5%. We began to investigate why this group had such high Emergency Room utilization. Questions we asked included:

• Do employees live in rural communities where this was their only option at certain times of the day?
• Does the current plan design encourage ER visits?
• Do employees understand the medical reasons that validate an ER visit?
• Are other Urgent Care facilities available in each community that employees could visit?
• What were the diagnosis and prognosis for each of these visits, and did they warrant an ER visit?

After analyzing the answers to these questions, we determined:

• Benefit overpayment existed with minimal education on the utilization of the ER.
• Employees/dependents were using the ER a majority of the time for non-threatening illnesses.

To resolve these issues, we recommended the following:

• Immediately change the benefit to a $200 copay from $75
• Hold mandatory meetings for their 600 employees to educate them on the benefit change and the use of the ER “life or limb threatening illness.” Employees were also given a listing of all urgent care facilities in there area. This list included address, phone number, office hours and what types of illnesses these Urgent Care Facilities could treat.

The employer immediately experienced the following results:

• ER claims fell below 1.50% of total claims
• Potential savings by stopping this early in the year were estimated around $175,000 or 6-7% of total claims.

Success Story 2: Implementing technology to reduce costs.

Through our Third Party Administrator, Employee Plans, LLC, we successfully implemented a claim management solution which has saved our clients, collectively, over $1,000,000 during the first full calendar year of 2007. This technological solution reviews out of network claims, analyzes actual claim data against nationally recognized claim edits and provides a leading edge in identifying potential fraudulent billing activity. We are encouraged by these results and are optimistic the claim dollars saved for our clients will exceed this amount in years to come.

Success Story 3: Streamlining plans offered to reduce overall costs.

Through the introduction of a consumer driven health care model, we successfully implemented an HRA plan to a 150 employee healthcare provider employer. After analyzing the four "rich" traditional plan options currently offered, we determined the client was paying for insurance that wasn't being utilized by the majority of the employees. This was contributing to the consistent annual increases to the plan. Approaching their second renewal, they have enjoyed a dramatic decrease in utilization which resulted in a "zero" percent increase in the first year and they continue to enjoy an exceptional loss ratio contributing to a more controlled cost in their healthcare plan.