The Problem:

“We were always under the impression that our clients’ administrators/PPOs were ‘peeling back the onion’ on high dollar claims to ensure that they were being paid accurately. Appears that isn’t the case even though the documented protocols call for such reviews. We submitted a $1.8MM hospital claim to Relevant where the ASO applied their network discount and quickly cut a check for $1.2MM. After auditing the claim, Relevant saved our client nearly $300,000!! We will be using this service in the future.” – – Healthcare Consultant

The cost of healthcare continues to rise with no indications of slowing down!

  • A recent PriceWaterhouseCoopers study revealed an 84% increase in the just the last 10 years.
  • From 2010 to year-end 2013, $1 million+ claims increased by 1,000% and the trend continues.
  • Medical costs trend for 2017 shows another expected 8-10% increase.
  • With the ACA excise, health plans must continue to decrease spend.
  • Medical and Drug advancements continue to add to increased costs.

Therefore, it’s no wonder claims payers are seeking proven cost saving solutions!

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 most effective approach is to Negotiate settlements directly with providers. All settlements are completed with a sign-off from the provider.  As such, we have never had a settlement withdrawn or repealed.
  • Unfortunately, some providers refuse to negotiate or settle a claims.  When this occurs, our expert coders thoroughly review and analyze billed charges with a Medical Bill Review and Audit which many times uncovers coding errors, unbundling and even fraud.
  • Another strategy is to utilize our team of financial & insurance experts who are consistently monitoring true Usual & Customary fees, and apply their expertise and data to ensure that our clients are not overpaying for services.  The proper use of this strategy involves a complimentary analysis of the plan’s Summary Plan Document or Certificate of Insurance to confirm the appropriateness of applying UCR.  This strategy, many times, provides the client with savings that can be as high as 90% off of billed charges.

Negotiated Settlements

Our team 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 only Medical Claims Settlement SpecialistsTM in the industry.
  • In-network & out-of-network high-dollar medical claims.
  • Signed provider releases with no signed release ever being rescinded.
  • Continuous discount agreements.
  • Example:  $75,000 in radiation therapy treatment.  Negotiations secured a 40% discount, or $30,000 in savings per treatment.

Medical Bill Review and Audit

  • Reviewed by Certified Medical Billing & Coding experts for coding errors, unbundling, duplicate charges, etc.
  • We apply the Centers for Medicare & Medicaid Services rules and guidelines.
  • All audit recommendations and findings are compliant with federal and state statutes.
  • AMA guidelines and referenced coding norms are also utilized and referenced.
  • Example:  $2.7MM pre-mature infant claim with PPO allowed amount of $1.5MM.  Medical Bill Review & Audit found over $900,000 in savings

Usual and Customary Repricing (UCR) 

Comprehensive databases assist in determining fair and reasonable charges

  • Inpatient – Based on industry standards and self-reported provider data.
  • Dialysis – Self-reported data from 80%+ of U.S. dialysis facilities (See Dialysis Savings Programs page for more information)
  • Pharmaceutical – Manufacturer self-reported pricing for 200,00+ scripts & OTC drugs
  • Example:  Hospital claim totaling $971,000.  After analysis and review of the Plan Document, a UCR savings of $624,000 was achieved.

What Makes Relevant’s High Dollar Settlement Solution Different?

  • Relevant offers a number of different solutions to meet the needs of the client, and to address the individual specifics of the given claim under review:  Negotiations, Medical Bill Review & Audit, UCR/AWP/Medicare Plus Repricing.
  • Negotiations and repricing services are contingency based—no savings, no fee.  Medical Bill Review & Audit priced very reasonably at a % of the billed charges leading to a strong ROI.
  • Our staff expertise and services are geared to provide that missing financial case management in the form of ongoing coordination and communication between the Reinsurer, MGU/Carrier, TPA, Case Management, Broker, Plan Sponsor and the Provider to maximize savings.