SPECIALTY RISK MANAGEMENT VENDORS

SLG Benefits maintains valuable relationships with numerous specialty vendors with expertise in claim cost management. These include outcome-based transplant networks, dialysis cost containment networks, specialty pharmacy benefit managers and claims negotiation/hospital auditing firms.

Outcome-Based Centers of Excellence

Improving technology and increased awareness have contributed to the increased frequency of solid organ and tissue transplants in recent years. SLG Benefits is able to assist plan administrators with the complicated transplant process through our contracts with several Outcome-Based Transplant Networks. Within a Transplant Program, the hospitals and their respective transplant teams focus on limited and specific transplant procedures. Each Transplant Program is required to meet strict credentialing criteria with respect to length of stay, complication rates and number of re-transplants. In addition, the Transplant Program will typically offer case rate pricing for the entire transplant continuum of care.

SLG Benefits’ goal throughout this process is to provide the claimant with the opportunity to choose the right facility for their procedure based on published medical documentation. In addition, the Plan Sponsor secures the entire procedure at a fair price, protecting them against inflated charges due to complication potential and cost-shifting. There are not many areas of healthcare that can have such a dramatic impact on both the Plan and Claimant. The Plan Sponsor typically benefits through more consistent stop loss premium increases due to fixed provider pricing and for a claimant with a $1 million limit, their benefit dollars have the potential to go a lot farther.

If our medical staff determines that the proposed treatment may include organ or tissue transplantation, we will provide the TPA with information on transplant facilities that currently participate in an outcome-based Centers of Excellence network. Outcomes data is a valuable tool for case management and can be provided to assist the claimant in the facility selection process, if requested. Our medical staff will work closely with the TPA and case manager throughout the entire transplant process and serve as a liaison between the transplant network and the TPA.

Dialysis Cost Containment

Renal dialysis treatment is another area in healthcare where self-funded plans bear the highest cost through provider cost-shifting. Roughly 80% of all renal dialysis costs are paid by Medicare, 10% by Medicaid and Veterans Programs and 10% by the commercial market. With Medicare, Medicaid and Veterans Programs price-controlled by the government and fully insured markets using their buying power to negotiate significant discounts, it’s easy to understand why costs have risen so dramatically for the self-funded population. SLG Benefits can recommend several vendors who offer access to national dialysis networks, providing Plans that use them the buying power needed to control costs. The network is built through relationships with quality providers and contracted rates that offer unparalleled economic value for the Plan. Through the use of specialty case managers, our recommended networks also provide valuable education for both claimants and employer groups. Utilizing a dialysis network offers the self-funded plan the greatest opportunity to preserve benefits for employees and provide pricing parity for employers.

Specialty Pharmacy Benefit Managers

The rising cost of pharmaceuticals is a major concern in healthcare today. This is especially critical for people with chronic conditions who are on multiple high cost medications. SLG Benefits maintains relationships with several Specialty Pharmacy Benefit Management companies who provide specialized patient management services. Employer groups today rely heavily on their Pharmacy Benefit Manager (PBM) to control their prescription drug costs. What many Plan Sponsors do not realize is that the most expense drug therapies, those typically biotech in nature, cannot be delivered through the traditional PBM channels. Because there is limited competition and typically no cost controls in place, specialty pharmaceuticals are often a safe haven for cost shifting within the healthcare provider chain. Specialty PBM’s are a necessity today for all self-funded plans seeking to control runaway pharmaceutical costs and preserve valuable plan benefits.

Claim Negotiation and Hospital Auditing Services

SLG Benefits’ Risk Management department can assist TPA’s in their effort to maximize claims saving’s, ensure optimal discounts on all out-of-network claims and aggressively pursue all charges felt to represent cost shifting. SLG Benefits has relationships with several national vendors who offer a suite of claim negotiation and auditing services designed to control costs and preserve valuable plan benefits.