April 20, 2020

Healthcare arbitrage #6: Other tactics

Cedric Kovacs-Johnson

In the final installment of our recurring series on healthcare arbitrage, we round up a few other tactics which don't require as much ongoing involvement, but which can still provide important savings opportunities.

In addition to the five healthcare arbitrage tactics we’ve laid out in this series, there are a few other tactics which can provide important opportunities for a plan to save money, but don’t require as much involvement from the benefits advisor or plan sponsor. In this post, I’ll briefly lay out three of these tactics.


FW&A monitoring

Our healthcare system is full of wasted money. One major avenue for this waste is erroneous claims. Some of these errors are honest mistakes, and some of them are intentional—such as upcoding care to make it more expensive.

Fortunately, we have the technology today to automatically monitor claims for fraud, waste, and abuse (FW&A) and edit them appropriately. The plan’s TPA should be able to integrate an FW&A monitoring program into their claims processing system.


Clinical trials

Health plans typically don’t cover experimental or investigational treatment. So if a member’s doctor recommends a treatment in this category, it will be up to the member to pay for it themselves (or get a different treatment). However, when a member participates in a clinical trial, they often receive the care being studied for free. This removes the financial burden for the member, even though the care isn’t covered by their plan.

It’s typically up to the provider to recommend any relevant clinical trials. However, the plan’s member support team can engage members to help them understand their options and the associated costs.

Black swan events

Black swan events are high-cost, often one-off events that typically aren’t regular occurrences for a health plan, but that plans should still be prepared for. Examples of black swan events include air ambulance trips or a member developing end stage renal disease. The cost of both of these events can be significantly reduced if the plan has a solution already in place and ready to be activated as soon as the event occurs.

Plan sponsors and their benefits advisors should work with the plan’s TPA to make sure solutions are in place for various black swan events.


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