In my consulting practice, I work with large, really large, and small payers – insurers and self-insured employers, as well as managed care firms – on managed care, claims, and related issues.
One of the best claims-managed care programs I’ve come across is at a relatively tiny insurance company. They have (generally) excellent relations with providers, tightly integrated medical management, claims and bill review, a keen grasp of cost drivers, and highly effective specialty programs. Their network penetration (albeit in a network direction state) is just under 90%.
Their results are impressive.
Medical costs (on a per-claim basis) for lost time claims have dropped dramatically over the last two years. While the industry’s costs were going up by 7.5% (NCCI stats), their clients enjoyed a double-digit decrease in medical expense.
How is this possible? They don’t have access to the actuaries, statisticians, or clinical experts resident at larger payers. They can’t afford expensive IT initiatives, integration projects, and sophisticated rules engine-driven document management processes.
What they do have is focus, an open mind and willingness to try new things, a commitment to do the right thing, and very little patience for bureaucracy. They also have medical folks doing medical management – the adjuster has the final say, but it is rare that the clinician’s recommendation is overturned.
I’m convinced the reason this payer is as successful as they are starts with and is driven by their culture and commitment to doing the right thing. Too often big payers’ plans get bogged down in the cloying mud of committees, process, debate and discussion. Internal rivalries and turf battles suck the life out of promising ideas. Individuals are far more concerned with looking good and checking boxes off their annual goals than actually making sure the programs reduce costs and improve outcomes.
Meanwhile costs continue to go up and care is less than optimal.
What does this mean for you?
It doesn’t have to be that way.
Mar
27
Do share! Who is this ultimate payor? I’d love to research their practices and learn from them.
I don’t know who the firm is that Mr Paduda referenced, but the results sure do sound like those my company (a small Florida based operation) achieves.
I’ve never figured out why buyers think bigger national is better. The ultimate analysis should be total case costs coupled with injured worker satisfaction, good medical provider relations, and best practices in place. Too many payers emphasize hourly rate rather than having the sense to look at the big picture and outcomes.
Good luck to the small firm Mr Paduda is talking about. They’ve got it right. Makes me wonder why so many payers continue to get it so wrong and are never punished by the marketplace.
It also sounds like the managed care company I worked for. We had the lowest rates in the industry, so to compensate we paid 99.5% of clean claims within 10 days and credentialed new providers in under 30 days. Once providers got over the rates and saw how much money we were saving them in reduced billing headaches, they were loyal.
If only more payers put service to their providers and members at the top of their priorities…
OK – Who is this well grounded organization that focuses their efforts so effectively? I have heard a lot of the “doing the right thing, right now” priority hype. Would love to refer clients to the organization you speak of.
Two different commentors indicate that the referenced firm is either their current or former employer – but no one is proud enough to name names of the firm. That speaks volumes to my ears. If you’re so proud, please name names. As Lynn says – it would be nice to refer clients – but we can’t do that for a “no name” organization, no can we.
As I said in my original post – please tell; please name names. Referrals may be headed your way.
Well . . . I posted my company’s name & contact information, but it was removed, I guess because it’s obviously commercial and self-serving.
Sorry Lynn Hartzell & JulieBeth. I tried.