Out-of-Network & Medical Necessity Reviews among Top Ways TPA Identifies Significant Medical Claim Savings

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After studying a year’s worth of results from its medical claim review division, Cypress Benefit Administrators has identified out-of-network and medical necessity reviews as two of the top ways it was able to uncover more than $6 million in employer-client savings. Cypress and Argus Claim Review also report that coding checks and line-item audits played an instrumental role in cost containment efforts.

Cypress Benefit Administrators
Through Argus, we have a vigilant medical claim review and negotiation process in place, and our staff is constantly monitoring several focus areas and trigger points.

In its comprehensive analysis of medical claims, Cypress Benefit Administrators and its Argus Claim Review division have recently identified out-of-network and medical necessity reviews as two of the most common ways savings are achieved on behalf of employer-clients.

The third party administrator (TPA) attributes millions of dollars in savings to Argus each year, with a total of $6.4 million saved in 2013.

As explained by Tom Doney, Cypress president and CEO, these in-depth medical claim reviews play a big part in the TPA’s role of helping employers contain the ever-escalating costs of employee benefits and keeping their overall expenses in check.

“In completing our latest yearly assessment of Argus results, we found that the average savings per file reviewed came out to $1,391.06,” Doney said. “Without such a focused effort on scrutinizing member health claims, savings of this magnitude wouldn’t be possible.”

Out-of-network reviews account for one of the top ways Argus finds medical claim savings because the charges billed by providers and facilities that aren’t under contract have varying pricing structures and can often be negotiated down, Doney explained. “Our claim review team has the experience to know when a charge seems unusually high, along with the negotiation skills necessary to come to a reasonable price.”

Medical necessity reviews are also highly effective in uncovering opportunities to save. “As our team is analyzing claims, there are many instances when the need for a procedure seems questionable or a test appears to be unwarranted,” Doney said. “Our claim review personnel are diligent about considering matters of medical necessity. They analyze hospital bills and follow up with any inquiries on a case-by-case basis.”

In addition to out-of-network and medical necessity reviews, Argus found coding checks to be a significant source of erroneous charges identified. Examples of common coding issues include receiving a charge for the incorrect service, being billed for a procedure at the wrong level or unbundling charges that should be grouped together.

By completing thorough line-item audits, Cypress and Argus have been able to pinpoint price-related issues as all individual charges are double-checked on bills. “Through Argus, we have a vigilant medical claim review and negotiation process in place, and our staff is constantly monitoring several focus areas and trigger points,” Doney said. “This kind of in-depth analysis is really worth the effort for companies of every size.”    

A privately held company headquartered in Appleton, Wis., Cypress Benefit Administrators has been pioneering the way toward cost containment in self-funded health benefits since 2000. The third party administrator (TPA) is the country’s first to bring claims administration, consumer driven health plans and proven cost control measures together into one package for companies ranging from 50 employees to thousands of employees. It serves employer-clients across the U.S. with additional locations in Portland and Salem, Ore., Omaha, Neb. and Colorado Springs, Col. For more information on Cypress and its customized employee benefits, visit http://www.cypressbenefit.com.

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Lori Van Handel
Willems Marketing
+1 920.750.5020
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Tom Doney
Cypress Benefit Administrators
920.968.4613
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