Retrospective Medical Claims Review & Recovery Program - Self-insured employers with 500+ employees on their plan:

This is not a simple claim audit! Our Claims Review & Recovery Program re-adjudicates all claims down to the claim-line level to evaluate whether they were billed, priced, and/or paid properly for both the plan and the member. The program makes them whole from any overpayments that have already occurred.

Traditional claims recovery programs offered by large payors focus on high-dollar claims, are restricted by provider contracts, ignore member overpayments, and are often a way of paying the payor to fix their own mistakes. In short, they leave millions of dollars on the table.

This claims review is truly an independent third-party review that aids fiduciary compliance. We review 100% of claims, regardless of claim size, and identify otherwise missed savings. Ours is the only solution that passes savings to individual members, reducing the overall cost of care for both the plan and the member.

Our Claims Review & Recovery Program is fundamentally different:

• Data mine 3 Years of Healthcare and Rx Claims

• Identify the entity that is overcharging, submitting billing errors, and overpaying claims.

• We contact the facilities/providers that received overpayments and recover your money. Employers and Employees receive collections.

• Recommend fully vetted new vendors for claim adjudication, network, administration, and Pharmacy Benefit Management when needed. Recommended vendors are 100% Transparent & do business to a Fiduciary Standard.

  This is not an ‘audit’. This a RE-ADJUDICATION of 100% of claims to meet Fiduciary Obligations.

  3-25% of plan spend is fraudulent, identified, and then returned.

  Example:

• 1,000 EE Self-Funded Plan (PPO/ASO)

• Annual Medical Spend = $10,000,000

• 3-Year Medical Spend = $30,000,000

• Conservative 4% Recovery = $1,200,000; 22% Recovery = $6,600,000

• Employer receives 50% of 4% Recovery = $600,000. And up to 22% Recovery = $3,300,000

Cost Modeling - Self-insured employers with 50+ employees on their plan:

Claim repricing and vendor vetting for replacing vendors with 100% transparency and business to a Fiduciary Standard. Implementing “Best in Class” vendors reduces spending up to 25% and improves Benefit Satisfaction.

• Data mine 24 months of Healthcare and Rx Claims.

• Reprice all consumed healthcare. This will illustrate any overcharging in your current claim adjudication process.

• Checking your PBM’s charges per script written will expose excess profiteering.

• Check your benefit vendors for accuracy and integrity. Recommend new vendors when needed for claim adjudication, network, administration, and Pharmacy Benefit Management. Recommended vendors are 100% Transparent & do business to a Fiduciary Standard which will increase benefit satisfaction and reduce benefit cost.

Pharmacy benefit manager repricing - all self-insured groups

• Through our fully transparent and trustworthy PBMs, our fully vetted PBMs offer genuine and provable savings on pharmacy costs by taking an unbiased approach to all things PBM.

• Through complete ownership of all contracts, processing of claims, passing all rebates to clients, and managing the network, our PBM consistently saves employers and employees significant money.

• Analysis found that prescription drug prices in the US are 2.78 times higher, on average, than in thirty-three other countries.

• For brand-name drugs, US prices are about 4.22 times higher compared with other nations.

• Setting industry standards for lowest-cost generic, name brand, and international drug fills.

• 100% Transparent and doing business to a fiduciary standard.

• Prescription drug costs can be reduced by up to 50%

Actuarial Group Modeling - Fully insured employers with 50+ employees on their plan, and analyze risk vs. reward in determining the better insured/self-insured solution:

• Innovative analysis to rigorously evaluate the opportunity for a group to move from fully insured to self-funded.

• Projected claims developed based on a robust historical claims experience analysis using a consistent and actuarially sound methodology.

• Simulation of employee enrollment in plans for the upcoming period based on the group’s experience.

• Calculate budget rates based on the experience analysis and predictive modeling of employee enrollment.

• Recommend new vendors for claim adjudication, network, administration, and Pharmacy Benefit Management when needed. Recommended vendors are 100% Transparent & do business to a Fiduciary Standard.

Fully insured employers have “No Chance” to control and/or reduce their consumed healthcare costs. Just because you become or are self-insured does not mean you will reduce your benefits spend. The employer needs actionable data, the best vendors, 100% transparency, and benefit partners working to a Fiduciary Standard. The employer can build a high-performance benefit plan with a custom-crafted solution.

Risk Decision Support - all fully and self-insured groups, sophisticated illustration of stop loss risk/reward profiles:

• Make an educated decision as to whether your group should self-fund or stay fully insured.

• Evaluate a group’s risk in terms of capital risk, return on capital at risk, and the likelihood of beating a fully insured (riskless) benchmark.

• Identifying the risk structure that meets the group’s risk tolerance level.

Actuarial Assistant - all self-insured groups, innovative analysis of plan cost dynamics:

• Compare, evaluate, analyze, and customize plan options

Experience & Migration Predictive - all self-insured groups, putting predictive modeling to work for you:

• The solution’s migration algorithm can predict where plan participants are likely to enroll given past benefit decisions (with three years of group’s claims) and simulated future requirements.

• Anticipate participant cost sharing and contributions, allowing benefits managers to complete the annual budgeting process.

 Advanced Benefit Design Institute is your Consulting Authority. If you like working with your Broker, retain their services. If you do not want to continue with your broker, Advanced Benefit Design Institute has Agents/Brokers that we can recommend.