Getting Medical Expenses Under Control: Researching & Reducing Claim Costs

Imagine you (or your client) is a large employer struggling with health care expenses and medical claims.

Across the board, employers are increasingly seeing a surge in liability claims, with settlements up more than 160% and underwriting losses spiking to $586 million last year—adding up to even more costs for employers.

But you can’t predict or control medical liability and expenses…can you?

When an employer tries to handle medical liability claims internally from a solely administrative or formulaic view, you are often limited by a lack of expertise and narrow scope of understanding and don’t always know what’s necessary (and available) for settling or negotiating. And that can cost you.

You’re not powerless in keeping medical expenses down after claims have been filed—that’s where our Medical Liability Review team comes in.

Meet the Team

Our Liability Medical Review team is comprised of nurses and board-certified physicians who collaborate on timelines and treatment plans to help deliver clinical-grade insights into claims.

After a claim is filed with an employer’s insurance plan, our team takes actions such as:

• Requests corresponding medical records and history.
• Looks for red flags such as unrelated treatments or pre-existing conditions.
• Has the specialty area physician/s review the itemized list of treatments to ensure they align with what’s relevant and necessary to treat the injury as well as industry benchmark guidelines (Official Disability Guidelines).
• Determines actual reimbursement costs vs. frequently inflated costs.
• Identifies any gaps in care plans.
• Comes back to the claims adjuster with a realistic coverage or settlement amount.

Client Case Example: A Metro Transit System

Our team works with one of the nation’s largest city-wide providers of bus and train services.

When a passenger submits a medical claim for an injury sustained on the transit system, our Liability Team conducts a thorough review of the claim and all related medical treatment. Supporting documentation, including medical records and accident video footage, is then forwarded to our Utilization Liability Review Team for evaluation.

Based on this review, a board-certified physician provides expert recommendations on which medical services were medically necessary, identifies any instances of overutilization, and determines the usual and customary costs for treatment.

This detailed analysis equips our liability claims team with informed talking points for negotiation and facilitates efficient resolution of the claim, including potential settlement discussions.

What Happens if a Medical Liability Claim is Denied?

If it is determined a claim may have been fraudulent, our team works with our in-house Special Investigations Unit (SIU) or one of our local investigative partner firms to provide a thorough review of the claim.

What Now?

So what should you do if you need help handling your medical-related liability claims? To learn what’s available and possible, reach out to our team.