By Jim Arnold CEO & Founder of finHealth

In evaluating claim expenditures for large self-insured employers, we often find that errors are made in processing healthcare claims. These “black & white” errors include exceptions such as duplicate payments, medical coding errors, age / gender conflicts, services billed not rendered, payment for non-covered services, improper diagnosis, patients that are no longer eligible for coverage and more. Additionally, we find exceptions where the cost charged to the patient was far beyond a reasonable, competitive rate for that medical treatment. Following are a few examples:





Regarding our chosen benchmarks above, Healthcare Bluebook is calculated based on the collective experience of 400+ self-insured employers as to what is a fair value generally tied to a “care bundle” provided to a patient in a given geography. Medicare benchmarks are far more precise, as these are computed based on that specific hospital’s cost structure, and the billing information associated with diagnoses codes, length of stay, discharge status, amount billed, etc. for that episode of care. The median cost represents the median for that specific medical treatment within that self-insured client’s health plan.
The payers are very protective of the claims data, which actually belongs to you as the sponsor of the self-insured plan, and are generally resistant to having their performance evaluated via a comprehensive audit. This is because it may not reflect well, and they run the risk of exposing certain contracting structures, that while very profitable for them, are not necessarily financially aligned with their self-insured clients.


If the amount charged to a self-insured plan for a given medical treatment is paid at more than 300% of Medicare, we believe that one of the six situations described below has occurred: