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ClaimCheck

August 31, 2021

By Joe DiBella, Managing Director, Executive Vice President, National Health & Benefits Practice Leader at Conner Strong & Buckelew

New technology, medications, and medical procedures have vastly improved healthcare providers’ ability to diagnose and treat severe illnesses.

These medical advancements are incredible for patients and can save lives. But they are also increasing the frequency and severity of large and catastrophic employee benefits claims. This can lead to financial stress for self-funded employers. In fact, a 2020 survey conducted by Sun Life found that nearly 25% of employers had at least one member with over $1 million in claims between the years of 2016 and 2019.

Large claims will become the norm as medicine continues to advance. In turn, employers need to ensure these claims are managed properly and that they’re not overpaying for certain procedures, treatments, and medications.

ClaimCheck from Conner Strong & Buckelew was built to help self-funded employers accomplish just that. ClaimCheck is a proprietary employee benefits claims screening process that closely examines large and catastrophic claims. It automatically ensures these claims are being properly managed by the complex healthcare system, adjudicated pursuant to the plan of benefits, and paid properly.

ClaimCheck follows a 5-step process that has been methodically developed, ensuring no large claim is overlooked or mismanaged throughout the course of engagement. Here’s how it works:

  • Step 1: A claim will be flagged for review by a Conner Strong & Buckelew clinical nurse once it reaches either $100,000 or 50 percent of the client’s stop loss deductible, whichever comes first. The claim is reviewed for eligibility, care management and ongoing monitoring to ensure all needed care management oversight is in place.
  • Step 2: If immediately needed, a clinical nurse will review the care management plan and options with the health plan’s care management team. When warranted, the claim will be elevated to the Conner Strong & Buckelew physician Chief Medical Officer for a more thorough clinical review.
  • Step 3: Once flagged, these claims remain under “open” management by the clinical team at Conner Strong & Buckelew to ensure appropriate care management. This ensures proper evaluation over the course of the engagement.
  • Step 4: Claims remain open until treatment is concluded and/or the client receives applicable stop loss payment. Even after payments are made, claims are monitored for ongoing appropriateness.
  • Step 5: Finally, any claim more than $200,000 goes through a case audit of the carrier’s adjudication accuracy of the claim to ensure all claims were paid properly.

With large and catastrophic medical claims on the rise, self-funded employers need to ensure these claims are being managed properly. Overpaying for an already expensive procedure or medication is not an option. With ClaimCheck, these business owners can rest easy knowing their claims are being handled as efficiently as possible.

Contact us for more information on how to ensure your claims are being managed properly.

FILED UNDER:

Employee Benefits

Practice Leader

Joseph M. DiBella

Managing Director, Executive Vice President, National Health & Benefits Practice Leader

More than 27 years of employee benefits experience

Previously led national and large account business for Horizon Blue Cross Blue Shield of New Jersey