The Pulse | Issue 21

To everyone involved in managing benefit plans, from the plan sponsor to the healthcare decision-makers, to the brokers, and administrators, now more than ever is the time to demand more from your solution providers.

The importance of managing high-dollar claims and high-risk members cannot be overstated when it comes to the financial stability of the plan and the protection of those members. These claims are complex, inflated, and often overrun with faulty billing practices and errors that don’t serve plans or their members well. But when you have a vendor partner working with you who understands the system and stands firm in defending plan interests and the interests of plan members, you gain more than cost savings. You gain control over the financial health of the plan.

MedWatch combines exceptional clinical insights with decades of cost containment expertise to ensure every dollar spent is justified, accurate, and defensible. This isn’t just theoretical; we see it in the numbers we achieve, we hear it in the appeals we win, and we live it in the outcomes we deliver for our clients every single day!

The spotlight examples below illustrate exactly what this looks like in practice and what’s possible when you stop accepting inflated claims and start demanding clean claims and accurate, fair pricing.

One of the costliest and most egregiously billed categories in healthcare today is dialysis. And for one of our clients, it came at a price tag of over $280,000 for only one month of treatment—until we stepped in.

When a member required daily, at-home peritoneal dialysis, the submitted charges for one month totaled more than a quarter million dollars. Our RN clinical review team knew exactly what to look for related to inappropriate and unbundled charges, to produce a “clean claim” that could then be repriced accurately. Through a comprehensive assessment of the billing and coding, we identified over $118,000 in inclusive and inappropriate charges. Once these were removed, the remaining allowable charges were repriced ensuring the client received a fair and transparent price. Because MedWatch has a proven process in place, these repriced claims are fully defensible, which we do for the life of the claim.

This resulted in a final payment of just $13,646.40, with total savings exceeding 95%. And because MedWatch charges a low flat fee for our Dialysis Claim Review & Repricing solution and not a percentage of savings, the plan not only had significant savings on the claim but paid a minimal fee for our service. A true win-win outcome. That’s the MedWatch difference of real savings creating a meaningful impact.

Out-of-network claims are some of the most volatile and inflated charges plan sponsors face today.

In a recent case, a claim for the removal of a pilonidal cyst was submitted at more than $108,000. A deeper dive into the charges revealed the extent of the inflation: one CPT code alone was billed at over $60,000. On top of the excessive CPT billing, the provider had also unbundled services and tacked on another $47,714.50 in inappropriate charges.

Once these issues were identified and addressed, MedWatch used Medicare cost-to-charge data from the provider’s geographic region and determined a reasonable allowable amount to calculate the recommended payment. The final payment was set at $3,191.90, resulting in 97% savings for the plan.

Cases like this are not rare. They’re part of a growing trend, and it takes clinical rigor and pricing expertise to push back. Plans that access these services—clinical review, and repricing of high-dollar claims—can realize significant savings that benefit the plan, plan member, and can help minimize costly increases in stop-loss premiums.

When high-dollar claims threaten to derail the financial stability of a health plan and its healthcare budget, MedWatch is your strategic ally that can make an impact. We go beyond claims review and billing audits to advocate for clients and members. Our ultimate goal is to provide the best clinical and financial outcomes for all stakeholders, which is why our high-dollar claim review services are among the most detailed and effective in the industry.

Our comprehensive claim review looks at dialysis, air and ground transport, high-cost pharmaceuticals, out-of-network services, and more. These claims often carry a high degree of risk, but also a high opportunity for savings when reviewed properly. Since we began reviewing dialysis claims in 2012, we’ve never lost a single appeal. That’s the kind of track record that is built on clinical precision and an extensive repricing experience.

MedWatch’s flat-fee model for our Dialysis Claim Review and Repricing service removes the costly percentage-based savings fees common in this space, translating into even more savings for our clients. We also support our dialysis carveout program with suggested plan language, provider sign-off, member advocacy, and 100% defensible reviews, which all come together to reduce claims on average by 92%, but with more egregious billing, we are seeing savings top 95% in many cases.

And it’s not just about savings. It’s about sustainability. The right claim review partner can reduce stop-loss premiums, eliminate balance billing stress for members, and create long-term predictability in an increasingly unpredictable healthcare economy.

With more than 37 years of experience and a full suite of population health solutions, MedWatch is committed to helping employers and plans build smarter strategies for cost control and care management.