Claim Payment Services
In an era when our contemporaries have reduced their margins by automating their services, the management of EGP recognizes that the true value provided by our organization is derived from the contributions of professionals dedicated to servicing our clients.
Managed care provisions and the associated provider discounts cannot effectively control health care costs without the necessary check and balance system provided by a claim manager. Our claims management system has been effective in curbing medical inflation, which has enhanced our ability to provide premium and claim expense stability.
Our Claims Department is committed to reducing claim turnaround time, enhancing client service and ensuring payment accuracy. Payment accuracy includes benefit plan provision enforcement as well as medical necessity and usual, customary and reasonable (UCR) determinations.
- Personal Service
Each claims adjustor is assigned a specific list of employer groups. That means plan participants communicate with the same individual when there are claim questions. Adjustors are familiar with their assigned cases – including individual medical and claim histories – which improves efficiency and leads to active claim management and case management referral.
- Consistent, Efficient Claims Processing
Each claim received is processed by the same adjustor from start to finish. Each adjustor is assigned maximum payment amounts, and claims in excess of these amounts must be reviewed and approved by the manager or supervisor. An internal random claim audit procedure is also followed.
- Objective Determination of Medical Necessity
Medical necessity determinations are provided by an independent medical consultant firm. Reasonable and customary levels are provided by data from Medicode UCR tables or through the medical consultants.
- Thorough Review of In-patient Hospital Billings
All in-patient hospital billings, which meet specific criteria including a minimum dollar amount, are audited by our medical consultants. This audit consists of a review of the entire medical file and a comparison to the itemized billings.
- Hold Harmless Protection
EGP provides access to Hold Harmless services as a protection for plan participants against collection of charges which were determined to be not medically necessary.
- Major Medical, Dental, Vision, Prescription and
Disability adjudication
- Detail claim financial performance reporting
- Coordination of benefits investigation and integration
- Third-Party subrogation identification and recovery
- Precertification, Utilization and Review, and Case
Management
For the purpose of precertification, utilization and review, medical claims auditing, and case management, Enterprise Group Planning subcontracts with specialized providers.
The utilization management program takes a hands-on proactive approach to managing health services. This approach involves basing certification on medical necessity, being involved daily in each case, and reviewing the quality and efficiency of care.
Communication with the patient, physician and hospital is critical to ensuring the best possible care for the patient and provides for a valuable resource to the family as a guide through today's health care system.
Case management provides significant claim cost control through the referral of specialty providers, recommendation of methods of treatment, and the negotiation of fees. It also promotes your organization by building significant goodwill with the family of the patient who benefits from the advice, counsel and support of a professional nurse during a period of personal stress.
