Is your network carrier providing all the savings available to your self-funded health plan?

Do you know carrier networks update reimbursement policies regularly to clearly define disallowed charges?  The self-funded community assumes the policy updates result in greater savings.  But do they?  Not necessarily.

Why?

Many network carriers now offer itemized bill review (IBR) for large dollar and complex claims because facility bills paid at a percentage of billed charges or bills that exceed a per diem must be reviewed to adhere to reimbursement policies.  Network carriers want automation in payment, but the abuse of the itemized bill by the facility has made automation challenging and bills must be reviewed manually.  IBR is rarely done and many networks, when requested, have to send the bill to a third party for a review.  The most common reason IBR is rarely done:  Reimbursement policies are characterized as "guidelines" with many disclaimers and can be superseded by provider contracts, which may prohibit any review.

What can a self-funded health plan do?

Although the reimbursement "guidelines" can be superseded by provider contract, the language in the plan’s Summary Plan Document (SPD) supersedes the provider contract as stated in the networks reimbursement policies.  In order to ensure that the self-funded plan is getting all the savings available, we recommend, the following language in the SPD:

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