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Cost control features result in significant plan savings by Cost Control Features
. . . 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. 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. 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. 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. 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. Pinnacle currently works with various vendors for large case management and offers clients an integrated program with 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. |