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Cost Plus. Plan Components. Claim Process. Claim Audit Duplicate Charges Medical Necessity Claim Re-pricing Cost Plus 12% Margin or Medicare + 20% _______________________________________ Frequency 100% Cost ?. Appeals Provider Files Appeal

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Presentation Transcript
Cost plus

Cost Plus

Plan Components


Claim process
Claim Process

Claim Audit

  • Duplicate Charges

  • Medical Necessity

    Claim Re-pricing

  • Cost Plus 12% Margin or

  • Medicare + 20%

    _______________________________________

    Frequency 100%

    Cost ?

Appeals

  • Provider Files Appeal

  • Full & Fair Review By Independent Expert

    _________________________________________

    Frequency 7%

    Cost ?


Liability exposure
Liability Exposure

Balance Billing

Law firm inserted between patient and provider.

________________________________________

Frequency 50%

Cost ?

Lawsuits

Insurance policy indemnifies the Plan, patient, TPA and broker/consultant

________________________________________

Frequency 0%

Cost Retention & Premium


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