The cost of health care benefits is among the largest expense items for most employers. Along with comprehensive healthcare reform, self-insured employers are facing additional pressures to ease the financial strain through conducting audits of their benefits plans. Industry experts in Human Resources along with Internal Audit executives commonly recommend that all sponsors of health care benefit plans periodically conduct an independent audit of their third-party claims administrators. Many employers have never conducted an audit, yet they provide draft authority on their bank account for the third-party administrator to issue funds to pay the organization’s health care claims. Increased scrutiny by the Department of Labor relative to proper discharge and monitoring of fiduciary duties by employers and/or sponsors of group health plans may be reason enough to conduct an audit. Plan sponsors put a lot of effort into designing health care benefits for their employees and want to be assured that these benefits are being provided at the right cost.
No one company handles every aspect of healthcare cost containment. As our client’s “savings integrator”, Optelcon has developed the “Optelcon Healthcare Cost Containment Network”. This is a network of pre-screened healthcare, cost containment, and specialty companies. The network is made up of innovators and leading specialty cost reduction and containment firms that deliver results. Under one umbrella, Optelcon provides our clients with a mix of capabilities and expertise that you will not find with any single healthcare cost reduction company. Only companies that exhibit the highest skill, and integrity and are clearly passionate about saving clients’ money get the opportunity to work with Optelcon’s clients.
Below is a listing of popular comprehensive benefits auditing solutions for both self-insured and fully-insured organizations.
Optelcon’s MBR audits focus on accurate billing and coding of Inpatient claims using the billing/coding rules and guidelines established by the Centers for Medicare and Medicaid Services (“CMS”), which create the standard billing/coding practices for facilities in this country. Our MBR audit services also take into consideration coding norms from other well-respected authoritative sources and industry publications (e.g., the American Medical Association, also known as the “AMA”). In short, the results and recommendations presented in our MBR audit reports are sound and extremely defensible. Such areas of focus include:
Optelcon MBR Audits focus on line item costs. The TPA may have paid a claim correctly, but the line item cost may be in error or egregious. i.e. $250 for an aspirin, 2 beds for one person, a shoulder MRI for someone diagnosed with the flu, tests or procedures that do not correlate with diagnosis, etc. We audit each line item BEFORE the TPA or PBM adjudicates the claim. The funds from disputed charges are not paid until confirmation of the accuracy is completed by our team. This prevents the TPA or PBM from taking errant claim amounts from your account in the first place. Like the IRS, it’s a lot harder to get your money back once it has already been paid.
Below is a listing of popular comprehensive benefits auditing solutions for both self-insured and fully-insured organizations.
Electronic claims payment systems minimize errors, but the complete claims payment process relies on human judgment. Multiple combinations of factors exist that attribute to claims payment issues such as:
Audit IQ is a Health care claims auditing software designed to efficiently and effectively identify errant payments. Users include Insurance Carriers, Third Party Administrators, Self-paying Employers, Employers, and Employee Benefits Consultants/Brokers.
FiLTER iQ is an intelligent and highly selective software analytical engine that can interpret and process benefit design logic. FiLTER iQ is the foundation for AUDiT iQ™’s modules: Medical, Dependent Eligibility, Rx, and Dental.
The Medical module comes complete for auditing all aspects of a medical health plan and its associated claims data. A comprehensive set of medical codes are included with the software and are fully integrated into the auditing process. These code sets include AMA CPT®, AMA HCPCS, AMA ICD-9, and CMS Revenue codes. The Medical module is based on over 80 categories that have been pre-tuned and configured out of the box to use the most appropriate medical codes available. In addition, each category can be configured to capture benefit design metrics related to deductibles, co-insurance, in-network / out-of-network payment levels, dependents, maximums based on occurrences or incidents, and others. Some examples of audit categories include:
The Rx module is tailored for pharmaceutical claims. Categories have been created to effectively audit many aspects of any pharmaceutical benefits plan including co-pays, exclusions, limitations, AWP and MAC pricing discounts, as well as other criteria. It utilizes both historical and current databases published by First Data Bank to define the Rx categories and assist with the analysis of the claims data.
The Dental module comes pre-configured with categories that effectively audit dental claims. Using the American Dental Association’s Current Dental Terminology (CDT) code set, AUDiT iQ™ can intelligently assess benefit design metrics related to co-insurance, exclusions, deductibles, maximum benefits, and others.[/accordion]
Dependent Eligibility Module
The Dependent Eligibility module is designed to accept various plan eligibility criteria and use those factors, along with the eligibility data, to build the communications/mailings, track each employee response, and report those responses in a real-time tabular or graphical manner.
On average, our clients achieve a 96% participation rate or higher with 2-10% of dependents found to be ineligible. By finding and removing these ineligible members from your plan, companies save an average of $3,000/year per member. This often means savings far exceeding the actual audit costs with returns on investment ranging from 100% to over 5,000% just for the first year alone.
The cost of healthcare continues to rise with no indications of slowing down!
We utilize a three-tiered approach to saving claim payors on high-dollar claims that ensures the most effective solution is applied on every referral so that we are able to obtain the highest level discount possible for our clients.
Our network of Certified Self-Funding Specialists, Certified Medical Coders, Certified Medical Billing Experts, Certified Municipal Finance Officers, Registered Nurses, and Master Negotiators work together to obtain savings for our clients.
The term “overpayments” refers to healthcare reimbursement claims that were, for whatever reason, paid at an amount higher than the amount owed by the health plan to the recipient.
There are many different causes of overpayments, such as duplicate billing, third-party liability, outright billing fraud, and several others. Many overpayments are impossible or prohibitively difficult to avoid; even the best-run plans commit them. In fact, overpayments are a relatively predictable phenomenon…and a costly one. Providers also utilize new billing technologies and Revenue Cycle Managers to create billing strategies in order to creatively get around administrators’ claims adjudication and payment processes in order to Maximize Revenues!
A 2014 report estimated the global average cost of overpaid health claims to be about 7% of all claims. The most recent analysis of Medicare claims puts the figure at 13% for the fiscal year 2014. What’s more problematic, recently expanded coding rules make claims even more complex! Health plans that rely on third-party administrators (TPAs) to administer claims on their behalf are believed by some to be at even greater risk. Although, self-funded employers using carrier TPA services under an ASO arrangement are also at great risk as these administrators DO NOT (although claim that they do) audit claims prior to payment, nor do they provide access to any of your claims data nor do they offer analytical reports to help you better manage your plan assets! In addition to those challenges, many times their own Network Provider Agreements actually protect those providers from audits and also disallow the application of standardized billing/coding rules set by CMS, OIG, NCCI, and other government regulatory agencies thus forcing the Plan Sponsor to overpay!!
Furthermore, health plans’ contracts with providers typically include an explicit right to recover overpaid claims. Of course, some overpayments are difficult and costly to detect. And detecting an overpayment is not the same as recovering it. Out-of-network providers, for example, may have little obligation or incentive to refund an overpayment. And a fraudster who has been put in jail – or fled the country – can be nearly impossible to collect from. And of course, recoveries take time – several months to several years after the paid date, depending on the situation.
Clients can reduce their medical claim costs by 2-4% or more off of their annual medical spend, and routinely receive double-digit returns on investment, by performing a Comprehensive Medical Claims Audit and Recovery project which only requires a total of approximately 8-10 hours of the client’s time over the course of the entire project (9-12 months in length). In addition to the opportunity for economic return, our audits help health plans and fiduciaries fulfill their legal and managerial responsibilities.
Audits are one of the most direct steps one can take to show that they have met their legal obligations in assuring that all plan expenditures are warranted and that plan assets are not misspent.
Our solution is a COMPLETE solution—Planning/Customization, Data Intake/Verification, Analysis/Audit Execution, Audit Reporting, and Full Recovery services that deliver recovered funds directly to the client. The various comprehensive audit modules utilized are as follows:
Cases for Focused Follow-up
Our network’s Post Audit Follow Up and Collection activities have analysts continuing to monitor claim payments and recoveries, reviewing payer collection efforts, and challenging case closures, where warranted. This results in Process Improvements and a more effective and efficient adjudication process for the client on a go-forward basis.
Healthcare costs are still on the rise, and pharmacy is a significant driver of that cost. With Medical inflation still in place but flattening, pharmacy inflation on the other hand is at its HIGHEST point in history!
Many sponsors of prescription drug benefit programs have operated on blind faith for too long. They have depended on their pharmacy benefit manager (PBM) to deliver safe and effective prescription drug coverage to their plan members while helping to reduce costs. The problem occurs when the plan sponsor relies on their PBM to tell them how they are doing. This is something akin to the ‘fox guarding the hen house’. To make matters worse, prescription benefit programs and PBM business practices remain some of the most opaque operations in health care (see our Industry News page for a number of articles on this important subject!). It is almost impossible for a plan sponsor to fulfill their fiduciary obligations without some type of independent, third-party oversight. This is where outside auditing and monitoring come into play. Let’s take a look at the reasons why:
The PBM Services Agreement is filled with plan definitions that dictate how terms are identified and open up the possibility for varied interpretations. PBMs contract separately with the plan sponsor and the pharmacy providers, thus creating ‘spread pricing’. Contracts also forbid any criticism from the Rx providers, sponsors, or auditors, and the terminology used is extremely ambiguous and ill-defined (MAC, Single Source Generics, AWP, Claims Exclusions, etc.)
PBMs prefer language that is vague and provides wiggle-room, meaning that a definition can be molded to comply with the business practice being deployed, usually benefitting the PBM. For example, even very basic definitions such as ‘Generic Drugs’ where Plan Sponsors are surprised to learn that drugs that should qualify as a generic (thus obtaining a greater discount) can be re-characterized as a brand (receiving a smaller discount), all at the discretion of the PBM.
The above-mentioned ‘wiggle-room’ also gives the PBM the flexibility to define pricing and rebates. For example when the PBM re-classifies manufacturers’ incentives into something other than a rebate or pricing discount. These lost savings accrue to the PBM’s shareholders rather than to the plan!
The health and welfare plan that includes the pharmacy benefit, may require an independent audit as part of the financial reporting to the Department of Labor. It’s IMPOSSIBLE for the plan’s financial audit to be completed accurately if the PBM’s performance is not also validated.
PBMs fight furiously to exclude themselves from being identified as a fiduciary in the vast majority of PBM contracts. As a result, the designated fiduciaries have an extra burden to make sure that the plan is performing.
Formularies are designed for PBM profitability, not health outcomes. PBMs maintain brand medications on the formulary when much less expensive Therapeutic alternatives are available and ‘rebates’ do not offset the price difference.
Clients can reduce their pharmacy claim costs by 10-25% or more per year, and routinely receive double-digit returns on investment, by performing a comprehensive Pharmacy Claims Audit/Recovery and On-Going Monitoring project which requires very little time and resources on behalf of the client. From a Retrospective Audit and Recovery perspective, clients can expect to recover on average 3% of their total annual spend for every year that can be audited. Most PBM agreements’ audit provisions allow between 24 and 36-month retrospective audits, with some provisions allowing audits back “to the date the contract was executed”. Additionally, an audit can identify whether plan members are paying the correct copays and whether drugs are being adjudicated properly. Via our On-Going Monitoring program, our network works with our clients to monitor the performance of the PBM on a monthly and quarterly basis to ensure compliance and identify recoveries and other areas of savings in near real-time – why continue to fund your PBM with overpayments on an annual basis?! Via On-Going Monitoring, we will ensure that you keep funds within your organization for the operation, success, and growth of your business!
Who is eligible for these services?
All health plan members are eligible for PBM Audit-Recovery & On-Going Monitoring services.
How does a member register for this service?
Members register their account by going to a dedicated website and entering in their last name, date of birth, and SSN. Once registered, members may request a review of their medications or they will be registered to receive proactive savings alerts on their mobile phones and/or emails.
How did Optelcon get the member’s information?
The network provider receives member information from the health plan and its vendors. Optelcon’s network is a benefit to all eligible participants and their spouses/dependents to advocate and coach them on methods to save on their prescription drugs. They have a team of pharmacists that search for ways to save and send alerts to the members regarding those opportunities.
How is member information used?
Optelcon’s network partners only use members’ information (demographic identifiers, prescription data, etc.) to find savings opportunities. They do not sell member information or release any prescription-related information to the health plan. The employer does not see any prescription-related information.
How do I save money?
Once your member receives a text or email alert from one of our partners, they log into their account and look for the personalized report in the “Reports” section of the member’s personalized account. A member can then download and print this guide complete with details on what savings were identified and step-by-step instructions on how to take advantage of that savings. For every $1 you save on your membership, the plan sponsor saves ~ $6!
Who do I contact with questions?
Should a member have any questions regarding his/her savings report, dedicated team members and numbers will be supplied to the Plan Sponsor and the members to address any questions.
How do I know Optelcon has my employees’ best interests in mind?
Optelcon has created a network of healthcare cost containment specialists that are pre-screened and passionate about saving their clients and their members’ money. We have spent many hours researching creative ways to save and want to deliver that information to you. Optelcon’s network will only deliver savings opportunities to members where real savings are possible. We ask members to always consult their physician, as we (and our registered pharmacist who supports this product) do not seek to replace members’ relationships with their physicians or pharmacists. We recommend members consider what we suggest because it will financially benefit them, and the plan, and is sound advice from a pharmacist.
How does it work?
One of the companies in Optelcon’s network will alert your members via email and/or text message when they find a savings opportunity. Upon receiving the alert, the member will log into his/her account and download a personalized report with step-by-step instructions on how to achieve savings. Everything they need to secure the savings is included in the personalized report. A member may also log into his/her account and manually enter prescription details and associated costs to receive a personalized report.
Why do members need to provide you with their email and mobile phone?
To maximize the methods by which we can contact your members about their savings opportunities, we ask that members register their email and mobile phone numbers. Members will only get a text message if there is an opportunity for them to save. We respect their privacy and will not contact any members unless they are able to save.
How much will the members save? How much will the plan save?
On average, our network identifies upwards of 44% in out-of-pocket savings for the members which equates to an average of 22% in overall savings for the plan. Savings analyses have reached as high as 38% for overall Plan savings. For every $1 saved by a member, the plan will recognize as much as $5-$6 in savings.
The Optelcon network’s Error Detection plays an instrumental role by utilizing advanced clinical editing (billing/coding Error Detection) technology to ensure that both institutional and professional claims are properly coded and compliant with applicable payer requirements. Error Detection examines the whole claim and identifies procedure-to-diagnosis mismatches, unbundling occurrences, use of nonspecific diagnosis codes, global service violations, potential unbilled revenue, and many other problem areas that can adversely affect not just claims to process, but a provider’s overall practice. This technology is deployed using cloud or client server-based technologies, and through the use of over 50,000 billing and coding error rules (based on commercial, Medicare, OIG, and Medicaid policies) resulting in millions of edit combinations, post-adjudication, and prior to payment of the claim, this technology identifies regulated billing and coding errors for both Professional and Institutional claims. Furthermore, customized rules can be created to meet customers’ specialized needs, and the unique editing, reporting, and workflow capabilities of our technology deliver significant cost advantages, maximum flexibility, quick implementation, and ease of use.
“Clinical Error Detection” as Opposed to “Technical Error Detection”: Errors are specific to the clinical coding aspect of the claim including unbundling edits, ICD/CPT® mismatches, global period violations, complete local medical review policies, correct coding initiatives, provider oversights and regulatory reporting whereas other solutions only edit technical aspects.
Average savings achieved from the utilization of this system ranges from 10% to as high as 30% and implementation is a matter of minutes! The system can utilize virtually any electronic file format and provides full HIPAA compliance under a secure internet connection to our highly secure Tier 4 data center (fenced facility, armed security, biometric entry, etc.)
What do you mean by ‘Real Time’ Error Detection and why should I care about that?
Due to the real-time functionality of the technology, depending on the number of claims within each file submitted daily, the system will analyze each file within a few hours on average. Therefore, all claims are made available to the client quickly so as to not affect the timeliness of claims payments to providers. Our network’s automated solution allows us to provide claims in real-time and get a sub-second response for potential aberrations. No manual intervention is required, substantially speeding up our claims processing. Historical data is stored at the processing source to ensure rapid processing for the detection of aberrations like once-in-a-lifetime procedures and fraud, waste, and abuse
Why do claims have so many errors?
As medical billing and coding continue to grow in complexity, there is simply more opportunity for errors to occur and as a result, the national estimate is $380 Billion per year is overpaid as a result. Human errors from keying claims into systems. OCR scanning errors as a result of inconsistencies and system limitations. And of course fraudulent billing errors as a result of medical providers attempting to find ways to maximize reimbursement levels and revenue. Given the high costs of systems and labor involved with claims review, and how PPO discounts mask the problem for payers, these errors are quite often missed in the adjudication and payment process. Furthermore, with the evolution of the Affordable Care Act which resulted in more patients entering the system and providers’ cost-shifting to the commercial space, coding errors are increasing daily.
Why is Error Detection important to me?
Proper and effective claims editing can lead to a number of savings opportunities and can enhance payer fiduciary compliance and responsibility, sales/marketing, and reduce costs:
How much can I save?
On average, the system will detect 10-30% of all claims reviewed showing errors. Of those claims detected, on average the savings will be 20%. In terms of dollars, on average each claim showing errors will reflect $300.00 in savings. As an estimate of savings, on a monthly basis, a population will generate one claim per life covered, per month.
What is a billing/coding Error Detection system?
An Error Detection system provides a payer the ability to avoid the adjudication, process, and payment of any claims codes that should not have been included on the claim, to begin with, due to either basic errors such as data entry, OCR scanning errors, etc. or coding errors as a result of mistakes as they relate to complex coding requirements and protocols. By ‘cleaning’ the claim prior to any adjudication, a claims payer ensures accuracy and avoids the payment of charges that should be denied.
What type of errors does your system identify?
The system contains Millions of Editing Combinations that are all automated. This robust editing includes the categories noted below:
Unbundling / Bundling – component / comprehensive • Regulatory errors – CPT® based regulations • Potential Fraud, Waste, and Abuse situations • Medicare RAC rules • Procedure/Diagnosis relatedness including LCD, NCD, and CPT®/ICD • Code validity – deleted or truncated codes • Utilization errors – limited occurrence codes • Billing oversights – missing associated services • Miscellaneous edits – by report procedure • Documentation – supporting documentation needed • Linkage mismatch • Missing and invalid data • Common coding rules • Place of service • Compliance with specific payer requirements • CCI violations • Global period violations – the follow-up to global service • Fee schedule editing • Gender and age edits • Utilization and historical
How much do you charge? What are the implementation fees?
There are no implementation fees of any kind. The Optelcon Network can also provide a complimentary analysis of one months’ worth of past paid claims to show the types of errors the system would have captured on those claims and the associated savings. When the system does detect errors that equate to savings, Optelcon only charges a percentage of that savings as its fee. If no errors are found, or the errors found do not equate to immediate cost saving, there is NO CHARGE to run claims through the system.
Do you help support your Errors should a provider question or appeal the edit?
Yes. The system provides an EOB with a full description and detail for any/all errors detected. In fact, we suggest to all clients to include a toll-free number at the bottom of the EOBs on any claims where errors were detected and savings were incurred that connects that provider directly with someone who can answer that question and explain the edit. Another option offered to clients is the creation of a client-branded web portal where the URL for this portal, along with a unique code, is added to the bottom of the EOB allowing the provider to access the specific defense text/source for any identified error. Furthermore, the system can provide a myriad of reports that can be generated by the client and in real-time regarding any claim or any specific error that was detected. Due to the nature of the errors found, appeal rates are extremely low.
As noted, average savings using a base of 200% of Medicare rates is approximately 43% off average “allowed amounts” (or nearly 50% from billed charges). Most clients choose to use a basis of 150% of Medicare rates. At this percentage, savings are more in the range of 57% off “allowed amounts” (or nearly 65% off of billed charges). However, because our network’s repricing model is built on Medicare’s rates vs. a % of billed charges, savings could be higher or lower depending upon the specific billing practices and/or demographics of the provider.
We understand that all clients are not alike. That is why we will work with you to build a tailored solution that meets your specific needs. This is a turn-key cost management solution.
Diabetic populations pose a wide array of challenging issues including but not limited to the following:
The following are the primary objectives of The Optelcon Network’s Diabetic Management program:
Our Blood Glucose Monitoring Program can provide these benefits and more. Through a partnership with Genesis Health Technologies, Optelcon’s network is now offering a program that is truly a “game-changer” for any chronic case management or disease management program dealing with diabetic members. Our network’s technology allows case managers real-time, instant access to patients’ glucose levels providing accurate and actionable information at their fingertips. Some highlights include:
Also, due to the fact all readings are recorded, this program eliminates test strip waste due to non-compliant patients. (It is estimated that approximately 65% of all test strips go unused!)
[Example of the many signs found all over the US]
Any day on the eBay website, one can find upwards of thousands of listings by individuals selling their unused test strips purchased by their health plans!
If the patient only tests once/day, when their supply gets low, they will automatically be sent a three-month supply – enough strips to cover their average amount of testing. No waste. The “true savings” over the longer term as a result of the increased Engagement within the Plan’s disease management programs are reduced hospitalizations, less frequent ER visits, avoidance of other disease states, less prescribed pharmaceuticals, and overall healthier members!
Optelcon’s (RHCC) Dialysis Claims Settlement Program saves an average of up to 90% off billed charges and often as much as 75% off standard PPO rates. Billed charges can and do vary by a large margin. However, our program normally saves $300,000 to $750,000 each year.
Optelcon’s network utilizes a unique approach to saving money including negotiated settlements, Dialysis Pre-Authorization or Carve-Out programs, and U&C adjustment recommendations.
Our average turnaround time for settlements is only 2 days. Should you need a case rushed, just ask and we’ll do our best to accommodate.
The average time for U&C adjustment recommendations is also 2 days. As with settlements, we accept special requests for expedited repricing.
*varies based on the multiple of Medicare utilized
Appeals happen. No program exists without appeals. And, when an appeal is received, we are here to help. We will review the provider’s appeal and provide you with a prompt response that can be used to formulate your own response.
To the right shows just one example of a person we saved over $645k in dialysis charges in just 10 months.
Dialysis treatments remove waste and toxins from the blood of a patient suffering from renal failure, allowing them to live without the natural ability to clean their own blood. Patients can be treated with Hemodialysis, which removes blood from the body and filters it through a machine and returns the cleaned blood back to the body, or Peritoneal Dialysis, which uses the peritoneum and a neutral solution called dialysate within the patient’s peritoneum to remove the waste by osmosis.
End-Stage Renal Disease (ESRD) is the point when the kidneys stop working and can no longer adequately remove waste toxins from the blood. ESRD is often the result of untreated diabetes and/or high blood pressure. ESRD is permanent so the only way to reverse the condition is through a kidney transplant.
The biggest factor in the price rise of dialysis is the consolidation of the industry. There are two major providers that make up two-thirds of all dialysis facilities in the country. Both are publicly traded companies that need to please their stockholders as well as their patients. Another reason dialysis is so expensive is due to the patient mix. For the average dialysis facility, approximately 85% of their patients are primarily covered under Medicare/Medicaid and the remaining 15% of the patients have commercial insurance as their primary coverage. The providers often shift costs to the commercial payers to make up for the lower reimbursement rates paid under the aforementioned government programs.
Medicare maintains a separate category for ESRD patients. Patients become eligible to apply for Medicare on their first date of dialysis. The majority of dialysis patients have Medicare part B as their primary payer.
The earlier we receive notification from the payer the better the chance of our success. Please review the codes below which can be used to identify impending dialysis cases as well as existing cases.
We recommend looking for the following codes that could indicate a dialysis patient is on the way:
Yes. When a patient completes home training, the three-month waiting period for ESRD Medicare is waived and the 30-month coordination period begins.
Yes, if the patient’s kidney transplant fails after the 37th month, there is an additional 30month coordination period with Medicare as the secondary payer, although there is no three-month waiting period in the second coordination period.
No, payers should pay the claims with the same methodology in the first three months as they pay the claims for the remaining 30 months of the coordination period.
Only a doctor can purchase a dialysis machine and a patient needs a prescription from a doctor to start dialysis.
It is a cost-saving program where group health plans add a dialysis pre-authorization phone number to their benefit card requiring dialysis providers to call our partner before patients begin treatment. This first point of contact with the provider is when allowable charges are first discussed and we work to negotiate the best possible rate.
Good plan verbiage provides group health plans the means to prudently manage their assets by clearly defining covered, non-covered, excluded, and allowable charges.
Our network’s Wrap PPO Network combines with (or “wraps around”) your selected Primary PPO network enabling maximum benefits and savings when your members’ claims fall outside your Primary PPO. We continually strive to provide the most extensive PPO wrap network coverage in the country and deliver timely results through a single-source solution.
In adjunct to our Wrap Network strategy, our network can include our Negotiations program on an automated referral basis. Assuming our Wrap program is the last attempt at network reductions, all claims that remain out-of-network can be immediately assigned to one of our expert negotiators. Once in their hands, they will contact the provider to attempt a settlement on the claim. Of course, customized parameters are set upfront to accommodate clients’ specific needs such as the implementation of negotiation thresholds: for example “a minimum negotiated a discount of X%”.
On average, our network negotiates successful savings outcomes on over 50% of the cases we attempt, with average savings of ~22%.
We provide national coverage offering over 2,100 locations nationwide should a patient choose to visit a draw station, or for even further convenience a patient’s physician can perform the draw in the office as long as the specimen is sent to our network for the analysis.
On average, Laboratory services represent upwards of 4%-4.5% of total medical spend and utilization is approximately 8-9 lab claims per year, per covered life with a billed charge average of $250-$300. With a savings average of 85% below the billed charge (or on average 30% below a payer’s current charges after PPO discount), our partner’s Lab Network can offer significant savings via a program that is also extremely easy to implement.
Optelcon can perform a complimentary savings analysis for anyone interested in this program. Simply provide the last year’s paid claims data for Lab in an Excel format. Within 3-5 business days, Optelcon will supply a detailed analysis of the potential savings.
Does the member have to go to specific locations to get their blood drawn?
No. Due to the structure of the program, a patient may have his/her treating physician perform the blood draw in the physician’s office. Or, if the member prefers, he/she may go to one of the network’s over 2100 draw station locations throughout the country.
Why utilize a program like this for my group health benefits program?
Group health payers can experience up to 85-90+% savings on any/all lab tests. We have yet to receive any past claims data from an interested payer where we were NOT able to offer significant savings. Rates in our exclusive, national lab fee schedule have not increased in over 10 years and are nearly as aggressive as the Medicare allowable.
How is Optelcon’s network able to do this?
Via exclusive distribution arrangements with national lab partners, Optelcon’s network partners are able to provide access to a very aggressive fee schedule for any/all lab services. Due to its aggressive nature, our partner will only allow us to offer rates at this level if the payer can meet the requirements noted above in this document.
How much does your service cost?
Optelcon can offer its network’s Lab solution under 1 of 2 different models – a PEPM model or a shared savings model, whichever is preferred by the client. No implementation fees and no fees for any due diligence such as savings analysis or Summary Plan Document reviews.
To implement the program, the payer needs to:
How many facilities are in The Optelcon Network’s nationwide network?
Approximately 1500 facilities in 25 states. Optelcon’s network also provides experts in building free-standing networks for our clients in areas where we may not currently have full coverage
What lab tests are available through Optelcon’s network?
Under Optelcon’s network lab network solution, more than 92% of all 80,000 series lab codes are included. Those not covered include various DNA tests and other more complex analyses, many of which are performed in an In-Patient setting. For any lab code that is unable to be priced under Optelcon’s network lab fee schedule, the client can simply submit those claims to the general PPO to secure savings.
Our Radiology Network & Concierge Service is a system set up by Optelcon’s network to better manage the cost and service of highly utilized and expensive diagnostic procedures such as MRI, CT, Arthrograms, CTA, MRA, and P.E.T./CT Scans. Through our actively managed Radiology Network, we direct patients to highly credentialed imaging facilities at greatly reduced rates and pass these savings on to you. Optelcon’s network includes an executive management team and scheduling department with a combined experience of over 250,000 diagnostic claims managed which resulted in more than $250 million in savings Nationwide Coverage.
Due to our innovative contracting strategy with our network providers, Optelcon’s network is able to provide our facility partners with a more valuable relationship as compared to the standard network relationships that exist today. As a result, we can secure a more aggressive rate schedule and greater savings for our clients, while at the same time delivering higher service levels to members.
Advanced radiology procedures continue to grow in cost and utilization. Most health plans experience anywhere from 10-13% of total membership having one of these studies ordered on an annual basis.
The key highlights of this program are as follows:
What is a Radiology Network & Concierge Service?
Our Radiology Network & Concierge Service is a system set up by the Optelcon network to better manage the cost and service of highly utilized and expensive procedures such as MRI, CT, and P.E.T. Scans for the group health and Workers’ Compensation industries.
What is ‘Concierge Service’?
For every referral received, an Optelcon network Care Coordinator will work with the patient and the patient’s treating physician to A. secure a copy of the prescription as the final QA of the official prescription for the test. B. perform Patient Pre-Screen to ensure placement of the patient in the proper facility. C. utilize mapping software to locate the most convenient location for the patient. D. reminder call to the patient the night before the test. E. provide driving directions and test preparation. E. send appointment notification to treating physician and pre-cert nurse. G. secure the medical report and proactively send to the ordering physician and pre-cert nurse if applicable.
Why utilize a program like this for my group health benefits program?
Group health payers can experience up to 40% savings on these highly utilized exams while actually increasing the level of service to their claimants/employees. Average savings nationwide per test is $500. A standard company should find that 13+% of total lives will need an MRI/CT or P.E.T. each year. Therefore, a 5,000 life company could save as much as $325,000.00 per year! Referrals can be made by phone, web, fax, e-mail, or by having the physician call. The average time on the phone for a referral is only 3 minutes! For 3 minutes of the member or physician’s time, the Optelcon network will save you $400. These savings are unparalleled.
How is the Optelcon network able to do this?
The Optelcon network has set up an actively managed Diagnostic Network of highly credentialed diagnostic facilities. We are able to direct patients to their centers at greatly reduced rates and guarantee a more rapid reimbursement. We in turn pass these savings on to our clients. We’ve set up a win-win-win scenario. The centers see patients that they would not normally receive, the payers pay less for the same exact tests, and the patient has the convenience of choosing their own facility that guarantees quality. Everyone wins.
How much does your service cost?
Nothing. No “per-member/per-month” fees, no percentage of savings fees, and no access fees. Our services are absolutely FREE. You simply pay a flat, global fee for the technical and professional components of the imaging test. The savings we capture for the payer are concrete bottom-line savings.
How do we get started?
Instruct clients or members that you would like them to utilize the Optelcon Network’s Radiology Benefits Management program. The Optelcon Network will take care of the implementation, and help educate adjusters/employees on the benefits of the services and how to use them. The Optelcon Network then provides all the coordination of these tests including, intake, pre-screening, offering directions to the facility, report procurement, and billing. Simply give us a call and we can arrange for a 30-minute meeting to go over the program in detail. If you can spare 30 minutes, you will learn how to bring these immense, free savings to your clients or group!
How many facilities are in the Optelcon Network’s nationwide network?
Approximately 1100 facilities in 32 states. The Optelcon Network’s team is also an expert in building free-standing networks for our clients in areas where we may not currently have full coverage
What diagnostic tests can be scheduled through Optelcon Network’s Healthcare?
MRI – MRA – CT Scans – P.E.T. Scans – Arthrograms – CTA
How long does it take to receive the medical report once the test is scheduled?
The average turn-around time from scheduling the exam to the medical report in hand is 4.5 days.