August 23rd 2023
The claims process for most insurers has become more efficient thanks to new technology and streamlined digital processes. Insurers also often hire consultants like the Davies Excess Claims Management team to review particularly complex claims. It pays off to have a partner to review the end-to-end claims process. Sometimes in the hundreds of thousands of dollars.
For example, in response to suspected errors, Davies was retained by a TPA to review a healthcare claim submission. A claimant receiving treatment for acute Leukemia underwent a bone marrow transplant and was hospitalized from November 22, 2021, to December 21, 2021. However, the patient’s coverage under the medical insurance plan was terminated on their discharge date, December 14, 2021, due to an extended period of work absence and the expiration of their medical leave. The claimant did not opt for COBRA upon coverage termination.
After a comprehensive review of the medical insurance plan’s documentation, the Davies team determined that the existing plan document did not explicitly state an individual’s coverage would end on the last day of the month in which coverage was terminated. Furthermore, the plan document did include provisions for coverage continuation during inpatient care, indicating that coverage would continue until the inpatient stay ends. However, the document lacked clarity on how coverage would be handled when a claimant’s coverage had already been terminated before the effective date of a new plan.
As part of the review, Davies experts reached out to the TPA to gather insights into their rationale for extending coverage through the end of the month following the claimant’s discharge. According to their practices, the claimant’s coverage would persist until their discharge date, then continue through the end of that month.
Upon further investigation, the team noted that the plan did, in fact, address the termination of coverage while the claimant was an inpatient, stating that coverage would continue, “…until the inpatient stay ends.” Since the claimant’s coverage had ended before the new plan document’s effective date, they would not be entitled to the benefits for any charges after December 21, 2021.
Consequently, the Davies team found the TPA paid for expenses after the discharge date in error. Through our technical expertise in analyzing contracts, agreements, and plan documents to identify ineligible expenditures, we were able to uncover unnecessary expenses and help our client understand the error to prevent the same issue from occurring in the future.
Our Excess Claims Management services include Employer Stop Loss [“ESL”] claim review, examination of policies, Summary Plan Document, and related coverage data on behalf of our clients who lack the technical level of support we can deliver.
The value of having a trusted partner in excess claims management extends beyond the immediate task of reviewing claims and policies. Leveraging our specialized knowledge, experience, and attention to detail help our clients maximize the value of their insurance coverage. Our collaborative approach ensures that clients not only receive the technical support they need but also uncover hidden savings that contribute to their financial well-being.
Learn more about our Excess Claims Management services by visiting https://davies-group.com/northamerica/solutions/insurance-services/excess-claims-management.
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