Rogue Claim Review
At Diversified Group, we understand that large claims need to be properly and effectively managed at all stages. One of the most important and unique programs that we offer to manage large claims is our Rogue Claim Committee.
The Rogue Claim Committee is made up of senior key members of our Claims Operations department as well as Registered Nurses/Case Managers and physician advisors from CMHS, which bring an essential clinical resource to the process. The purpose of the committee is to review case management and claim management opportunities through a process of reviewing available patient clinical information for medical necessity of treatment. It will also establish if facility and physician coding and charges are usual, reasonable and customary based on nationally accepted standards and protocols.
These weekly high dollar claim reviews also focus on other aspects of a claim, such as ongoing eligibility, prognosis, availability of other primary coverage, subrogation and fee negotiation (non-network claims). This professional review often results in better treatment outcomes and lower health plan costs.
Since its inception in 2007, our Rogue Claim Committee has saved clients over $2,300,000!
Healthcare Cost Containment
Diversified Group partners with The Phia Group, LLC, an innovative cost containment leader in the health insurance industry with expertise in providing services for self-funded ERISA plans. The PHIA Group recognizes the complex processes amongst the various entities to ensure smooth and efficient claims administration while protecting plan rights at all times.
The PHIA Group’s experience and unique claim extract program produces results that far exceed national averages.
National Average = 1 subrogation case for every 350 employees
PHIA Group = 1 subrogation case for every 65 employees
This ensures that all clients of Diversified Group and their group health plans are only paying for claims that should be the responsibility of the plan.
Providing End-Stage Renal Disease Cost Containment
Through our strategic partnership with DialysisPPO, a cost containment company, we are able to work with self-funded employer group health plans and implement changes to plan documents that capitalize on the unique reimbursement aspects of dialysis.
Kidney dialysis, formally known as End-Stage Renal Disease (ESRD), is the only medical diagnosis that entitles a patient to primary Medicare coverage, regardless of age, after a 33-month period. Unfortunately for our self-funded clients, the typical monthly charges from their dialysis provider are 1,377% of what Medicare would allow for the same services. It is not unusual for monthly charges to exceed $50,000. Hardly fair, but not surprising in a market where approximately 63% of all patients are treated by just two large provider organizations. DialysisPPO levels the playing field by transferring the pricing leverage from the provider to the plan. Their unique program entails an administratively simple modification of the plan document that establishes a defined fee schedule for dialysis services, and establishes a new, low-cost plan benefit that optimizes the member’s available coverage. Together, these modifications enable plans to reduce their costs by up to 80% after only 3 months of dialysis.
The Value for Our Clients:
Through this program, Diversified Group clients save an average of $397,000 per case annually. There are no implementation costs and our fees are based on retaining a percentage of the savings we create through our program.
Cancer Management Programs
Understanding the need for health plans to keep up with the extraordinary advancements in the treatment of cancer that science has achieved over the last 15+ years made the decision for Diversified Group to make OncoSentrics a key component of our cancer management program a relatively simple one. We introduced the OncoSentrics program to our suite of managed care solutions in 2010 with great success for plan members and their employer groups.
Biologics first introduced OncoSentrics in 2005 and has already received accolades from payors for its focus on evidence-based guidelines and integrated clinical care teams specifically for the treatment of cancer.
The OncoSentrics program was developed with the understanding that cancer is not one disease with one clear course of treatment. There are more than 300 distinct types of cancer, varying stages of disease progression and more new cancer medicines than ever emerging from manufacturers’ pipelines. And the world of cancer is constantly changing.
Along with positive developments such as earlier diagnosis, new promising treatments and longer term survival, come higher costs. Although, on average, plans have a 1% incidence rate for cancer diagnosis among enrollees, costs make up about 15% of a plan’s overall healthcare spend. Without a cancer management strategy, cancer treatment costs are projected to escalate at a rate of 233% in just four years.
Biologics’ singular focus on cancer, strong longstanding relationships within the provider community and determination to ease each patient’s health, financial and emotional burden has translated into a robust set of offerings designed to most successfully – and cost-effectively – manage cancer.
Each of the components of OncoSentrics leverage Biologics’ extensive oncology expertise to respond to the growing oncology services market, as well as to the highly individualized needs of cancer patients.