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Cost
Control Features
Cost control features, such as coordination of benefits,
duplicate payment recovery, third party liability, and
subrogation, result in significant plan savings
by eliminating duplication and overpayment of
claims.
Utilization review and large case management increase plan efficiency
while enhancing the level of care provided to
employees and their families.
Coordination of Benefits
Pinnacle
utilizes standard COB procedures in accordance with
the
National Association of Insurance Commissioners
regulations and federal law. COB information is
requested at the time of enrollment and maintained
on our system with effective and termination dates
according to the type of benefits (medical, dental,
vision) for each individual subscriber. When claims
are received, a letter is automatically generated to
the provider of service and the subscriber
requesting COB information. COB savings are tracked
and reported on an annual basis. Pinnacle's clients
are currently achieving average COB savings of 13
percent
Duplicate Payment Recovery
Pinnacle's claims processing system automatically screens
claims to prevent duplicate payments. The system
looks at several criteria and either pends the claim
for additional research by a claims examiner or, in
the case of a perfect match, generates a denial
letter to the provider of service. In the event that
a claim is overpaid, the claim is adjusted and the
amount automatically deducted from future claims
paid against the same provider. Refund requests
automatically generate to providers until all monies
are recovered.
Third
Party Liability
Pinnacle identifies third party liability claims for its clients and
assists in recovering monies owed to the employer's
plan. Claims identified by the system as potential
work-related injuries can be forwarded to the
employers' Workers Compensation carrier for handling
and determination of benefits. Typical
accident-related diagnosis are also automatically
pended by the system and a letter generated to
request additional information. If a response is not
received within 30 days, the claim is denied. The
claim is re-opened and re-processed once additional
information is received.
Subrogation
A report listing all
"potential" subrogation cases is generated by
Pinnacle's system and forwarded to our Legal
Department. Accident related claims are pended and a
series of lien letters are automatically generated
and sent to the subscriber for signature. If there
is no response, the claim is denied. If a signed
lien letter is received, Pinnacle's legal staff
processes the claim and initiates the recovering of
monies for the plan. All recovered monies are
forwarded to the client less a 10% administrative
fee.
Utilization Review
Pinnacle has the ability to coordinate with any
utilization review company designated by its
clients. We also provide our clients with an online
utilization review service. Pinnacle can
electronically integrate utilization review data
into our system for benefit payment calculations
including pre-certification for elective hospital
admissions, pre-surgical review for all outpatient
surgical procedures, and retrospective review for
review of additional days.
Large
Case Management
Pinnacle currently works
with various vendors for large case management and
offers clients an integrated program with
Anthem Blue Cross of California. This program provides
quality, cost-effective care by working with the
patient, provider and family to determine the best
method of long-term care.
The patient's benefit
plan, available community resources, and
negotiations with providers for reduced fees, are
all evaluated as a part of the process. Pinnacle
electronically integrates this information into our
health claims processing system to ensure that future
claims are paid according to the specified plan.
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