Actions speak louder than words and we believe our success stories speak volumes to our abilities to secure superior discounts on your medical claims. Here’s a small taste of the cases we have handled for our clients and the outcomes we’ve generated for them:

Settlement Success Stories:

A $154,726 Billing Error Uncovered
A hospital keyed the wrong dosage which resulted in $155,000 in charges. The PPO repriced the claim and the TPA was ready to remit payment to the provider subject to advance funding. The carrier sent the claim to EthiCare’s staff pharmacist who immediately recognized the error and contacted the provider. The provider, admitting they had billed incorrectly, issued a corrected claim. This saved the plan/carrier $154,726 they would have otherwise paid.

Chemotherapy Billing Error Uncovered at Government-owned Hospital
A federal government owned/operated hospital billed $73,377.06 for a chemotherapy treatment. EthiCare’s staff pharmacist reviewed and researched the treatment modality and discovered the provider had billed incorrectly. After a brief discussion with the provider’s billing office, they admitted the error and issued a corrected bill that same day. This saved the plan/carrier $69,150.16 they would have otherwise paid.

More than $900,000 in dialysis charges saved
EthiCare Advisors was retained by a TPA to help secure a deeper discount at an in-network dialysis provider. The TPA was very proactive and we were able to contact the provider before the provider had billed for their services. The existing percentage off billed charges PPO discount was increased from 25% to a fee schedule discount equal to about 70% off billed charged by EthiCare’s disease management director. The employer has saved over $900,000 and our settlement helped preserve the patient’s life time maximum benefit.

Snake bite victim almost becomes victim of overbilling
A claim for a patient bitten by a snake was referred to EthiCare Advisors because the provider was billing $10,549.10 per dose of Crofab for 6 doses. Upon review of the medical records, it was determined that the patient was administered one dose when the patient went into shock and the treatment was stopped. EthiCare Advisors reported the error to the provider who removed the $52,745.00 in incorrect charges.

Since when is homecare needed for the reconstruction of three breasts?
A claim for a female treated by a plastic surgeon for a breast reconstruction was referred to EthiCare Advisors by a claims analyst who felt the charges were a little high. Upon review of the claim, EthiCare Advisors determined the provider was billing the plan for the reconstruction of three breasts and for home care by an LPN. EthiCare Advisors reported the error to the provider who corrected the charges.

EthiCare’s Small Claims Unit saves more than 80% off billed charges
EthiCare Advisors’ small claims unit received several out-of-network physician claims totaling $41,579.00 for a 68-year old female patient covered by a self-funded healthcare plan. Our small claims team reviewed the charges and negotiated a settlement of $7,767.04 or 150% of the Medicare reimbursement as payment in full. This represents an 81.3% discount off billed charges or savings of $33,811.96 for the self-funded plan.

Why you should audit paid claims
An MGU sent to EthiCare Advisors a claim it received for reimbursement. The claim was for a 26 year old female patient who had visited a hospital in the New England for elective, medically necessary surgery. Patient was confined for six days and billed charges were $274,185.73. The plan’s TPA processed and paid the claim with a small PPO discount. This MGU has adopted a policy of auditing all claims where their carrier’s liability exceeds $100,000. The claim was audited and discrepancies totaling $179,727.00 (or 65% of the entire claim amount!) were uncovered by EthiCare Advisors. The majority of the discrepancies found were in duplicate billing and technical charges only billable by a physician, but were being billed by the hospital. EthiCare presented our findings to the MGU who in turn presented them to the TPA. The TPA requested and received a refund from the provider for the discrepant charges. $179,727.00 saved by EthiCare.

A true story of Financial Case Management:
EthiCare Advisors was retained by a TPA to help secure a discount at an in-network provider. The claimant, a 62-year old male, had a heart attack while on vacation 3,000 miles from home. The claimant was still in-patient when EthiCare Advisors began financial case management.

Our immediate goal was to get the patient back to a local facility and out of a hospital whose charges are among the highest in the nation.  We were able to provide pricing on air ambulances and select one that was able to immediately fly the patient cross county. There was a separate policy that covered this cost and was not the responsibility of our client.  However, arranging the air ambulance quickly was crucial for lowering the liability to our client.

Final billed charges at the initial facility were $463,000 and EthiCare Advisors was able to arrange a $139,000 discount.  Simultaneously we were able to negotiate a rate at the local hospital that saved an extra 20% above the PPO contracted charges.  Concurrently we worked to locate a local rehab center in order to move the patient out of the local hospital as quickly as possible.  We were able to secure a quality rehab center at 80% of their normal rate. 

In summary, EthiCare Advisors saved the plan and carrier $160,000 over and above any PPO discounts.  More importantly, our involvement helped save the plan and carrier money by getting the patient home and into a rehab center as quickly as possible. 

We were able to perform these services while the medical case management firm performed their services concurrently.  The $160,000 cash saving was the result of combining our in-network settlements, patient specific contracting and financial case management. 

The unquantifiable benefits include: fewer days spent in an extremely expensive facility due to our efforts in securing an air ambulance, identification and selection of a reasonably priced local rehab facility, time that the TPA claims staff didn’t have to spend performing these services and the value added services that the TPA was able to perform for their client and their carrier. 

Other companies specialize in large volumes of small claims.  We specialize in small volumes of large claims.  What impacts your business more?

EthiCare Advisors, Inc.
 Medical Claims Settlement Specialists™
One Maple Avenue - Suite 2G
Netcong, NJ 07857 USA
(888) 838-4422 ext. 3
(866) 662-4121 fax
info@ethicareadvisors.com

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