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RCI introduces the Dependent Eligibility Audit
Did you know that 5-15% of all dependents are ineligible and can be costing as much as $3,000 per dependent?  RCI can provide a dependent eligibility audit and provide a substantial savings for your self funded health plan.  Talk to your sales or account representative to receive a proposal.

Midland’s Premier Network
RCI is excited to announce the new Premier Midlands Choice Product.  Contact your Sales Representative or Account Manager for more information.

 


When an employer retains Regional Care to manage its health benefit claims we are being trusted with a significant budget item.  As such, we are committed to ensuring that each claim is subject to several controls, including: the edits,

security and automation in our system; an experienced staff with appropriate levels of authority in what they are able to adjudicate; and partnerships with specialty firms that maximize cost control opportunities.

Regional Care saves its clients over $0.20 on each dollar in claims through our controls:

System Edits and Automation:  Our Group Benefit and Administration System (GBAS) has been designed to automatically assign a specific benefit to each claim based on the provider, place of service, procedure and diagnosis.  This automation leads to consistency and a higher level of accuracy.  Once the benefit is assigned several thousand edits are applied related to the procedure vs. age and sex of the patient, the procedure vs. diagnosis and the procedure vs. place of service.  Any claim triggering such an edit is reviewed by our most experienced staff and our nurses.

Clinical Editing:  We have purchased sophisticated software to review provider billing practices for strategies to earn additional revenue.  Examples include code unbundling, upcoding and pre-operative and post-operative visits billed separately.

Out-of-Network Claims Management:  All claims received from providers that are not contracted with a PPO are forwarded to a business partner in an effort to obtain a discount through negotiation.  Discounts are gained on over 80% of the claims negotiated, with an average savings of 28%.

Subrogation:  All claims where there is potential of third-party liability are researched to determine liability and agreement gained from the participant that they will re-pay the Plan from proceeds of other coverage.  All claims with such agreement are tracked closely.

High Dollar Claim Review:  All claims with payments exceeding $25,000 are subject to physician review, with the patient’s treatment notes compared to claims detail to ensure the services provided and billing is appropriate.  If the physician identifies inappropriate charges the bill is negotiated with the provider.

External Claims Audit:  We have retained the services of an independent audit firm to review a stratified random sample of 3% of claims processed plus all claims exceeding $15,000 prior to payment.  Ongoing audit reports from this firm are used to develop training programs and other quality improvement activities.

Retrospective Surveillance:  Following adjudication all claims are forwarded to a business partner that applies several editing programs for fraud and other issues.  This “last look” at claims is an additional level of control that few TPAs have implemented.

Our clients are secure in knowing that we use every resource available to us so that the right amount is paid on every claim.

 

 

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