Shock Claims Management

Large Claims
A system designed to help stabilize premium fluctuations in smaller groups. Large claims (those over a stated amount) are charged to a pool contributed to by many small groups who belong and share in that pool. The smaller the group, the lower the pooling level. Larger groups will have a larger pooling level.

Benefit Administrators, Inc. is an experienced third party administrator (TPA) providing medical Shock Claim Management services to employers who self-fund their health plans. We offer a variety of services and guarantee outstanding client service to best meet your needs.

  • Negotiate competitive pricing to fit your plan needs
  • Provide the necessary data to obtain competitive quotes from top (A rated) insurance carriers
  • Customize a plan that is specific to your needs (For example, we help you choose a deductible level appropriate for the size of your group)
  • Analyze claim history
  • Assist in claim processing and tracking
  • Provide monthly financial reports
  • Review contracts to guarantee comprehensive coverage
  • Ensure that the Shock Claim policy mirrors your underlying benefit plan

Because insurance carriers come and go in the medical Shock Claim marketplace, it is extremely important to choose a company that’s financially sound, experienced, and reputable. Benefit Administrators, Inc. can help you with your shock claim coverage by offering you a policy from a carrier that you can trust.

As a service to the client, BAI coordinates the tracking and filing of all shock claims. Claims are monitored each month once they reach a minimum of $10,000, based on the client’s needs.

An updated report of all claims that reach this threshold is forwarded monthly to the client for their information. If the claim exceeds the specific deductible level, BAI will be responsible for filing all the necessary information with the carrier, as needed.

This process is acceptable to all of the reinsurance carriers that do business with BAI. As a result, claims reimbursements are issued in a timely manner.

COORDINATION OF BENEFITS (COB)

One of the major reasons for monitoring coordination of benefits is to ensure that the client is in fact the primary payor. Coordination of benefits (COB) applies to a person who is covered by more than one health plan. The COB provision and regulations require that all health plans and other payers (e.g., Medicare) coordinate benefits to eliminate duplication of payment and assist patients to receive the maximum benefit to which they are entitled. By adhering to the COB provisions, the health plans and other payers can determine which plan will pay for a claim first. The health plan or payer obligated to pay a claim first is called the “primary” payer and the other plan or payer is termed “secondary”. Together, the primary and secondary payers coordinate payments for services up to 100% of the covered charges at a rate consistent with the benefits.
A status audit is performed by BAI to determine COB for all claimants being monitored under shock claim. Three attempts will be made to obtain COB status. If after the third attempt there has been no response, the employer will be asked to assist in the investigation.
Any findings of other insurance that should pay as primary are investigated through the carrier to ensure proper payment.

CATASTROPHIC CLAIMS REVIEW

Each claimant during a contract year that has paid claims exceeding $50,000 is reviewed in great detail. Claimants are reviewed by diagnosis and procedure codes. This analysis is completed to determine if these claims are considered to be a short-term condition, a temporary longer term condition or if they are considered to be terminal. The case management departments will be contacted as needed to obtain additional healthcare information. Coordination of benefit audits are performed to validate there is no other coverage available that should be paying as primary. This includes investigations for possible accidents that could result in subrogation recoveries. Any subrogation or coordination of benefit information that we confirm is forwarded to the healthcare payer’s recoveries department for legal administration of recoveries or reprocessing.
Shock claim refunds for all claimants that exceed the specific deductible are tracked and compared against the paid claims for the contract year. Any unpaid amounts will be pursued aggressively. This ensures that all refunds that you are entitled to have been paid.

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