Reasonable value self insured medical benefit plan
View Patent ↗A self-insured or self funded medical benefit plan is provided by an employer wherein the self-insured medical benefit plan is governed by ERISA, and wherein the employer who is providing the medical benefit plan is 100 percent responsible for payment for medical services provided to an employee, receiving the benefit of the medical benefit plan, to a medical service provider for covered medical services and products. The medical benefit plan and method for providing the medical benefit plan determines a reasonable value for the medical services provided by a medical service provider to a participant of the plan, reprices a bill or claim from the medical service provider, and protects the participant/employee under ERISA from attempted collections of additional moneys that a medical service provider may believe is owed for the medical services but were not paid by the exemplary self insured medical benefit plan.
1. For an ERISA Medical Benefit Plan (EMBP) established by an employer for the benefit of an employee of said employer, said EMBP comprising funds for a payment of medical services provided by a medical service provider to said employee, a method of repricing a medical service provider bill, by a third party, for medical services provided to said employee, said method of repricing said medical service provider bill comprising:
receiving and storing, by the third party, said medical service provider bill data in a computer system, said medical service provider bill data comprising a description of a medical service, a code for said medical service, and a charge for said medical service;
checking, by the computer system, said medical service provider bill data for a medical service code error;
comparing, by the computer system, said medical service provider bill data with a calculated cost-to-charge ratio history or a calculated profit margin history for said medical service provided by the medical service provider;
determining, by the computer system, if the charge for the medical service comprises a cost-to-charge ratio or profit margin that is greater than the calculated cost-to-charge ratio history or the calculated profit margin history by a predetermined maximum amount;
comparing, by the computer system, said medical service provider bill data with medical service cost database data and determining if said charge for said medical service is within a predetermined range of acceptable charges for a same description of said medical service or a same code for said medical service within a same or similar geographically comparable area;
providing to the EMBP, by the computer system, a recommended repriced charge for said medical service being in accordance with an agreed upon definition of reasonable value for the medical service, the recommended repriced charge being based on a mathematical comparison and analysis of the calculated cost-to-charge ratio history, the profit margin history, or the medical service cost database data for the same description of the medical service or the same code for the medical service within the same or similar geographically comparable area, the recommended repriced charge comprising a lower recommended amount for the EMBP to pay said medical service provider for said medical service, an explanation of review document, and appropriate ERISA claim denial or partial denial language adapted to indemnify the employee under ERISA from the medical service provider collecting payments above the recommended repriced charge from the employee; and
negotiating electronically, by the third party, to get the medical service provider to accept the recommended repriced charge as being in accordance with the agreed upon definition of reasonable value for the medical service.
2. For an Employee Retirement Income Security Act (ERISA) governed Medical Benefit Plan (EMBP) established by an employer for the benefit of an employee of the employer, the EMBP comprising funds for a payment of medical services provided by a medical service provider to said employee, a method of repricing a medical service provider bill, by a third party, for medical services provided to the employee, the method of repricing the medical service provider bill comprising:
receiving and storing, by the third party, the medical bill provider bill data in a computer system, the medical service provider bill data comprising a description of the medical service, a code for the medical service, and a charge for the medical service;
checking, by the computer system, the medical service provider bill data for a medical service code error;
providing to the EMBP, by the computer system, a recommended repriced charge for the medical service being in accordance with an agreed upon definition of reasonable value for the medical service, the recommended repriced charge being based on a mathematical comparison and analysis of calculated cost-to-charge ratio history data, calculated profit margin history data, or medical service cost data base data for substantially the same description of medical service or the same code for the medical service within the same or a similar geographically comparable area, the recommended repriced charge comprising a lower recommended amount for the EMBP to pay the medical service provider for the medical service, an explanation of review document and appropriate ERISA claim denial or partial denial language adapted to indemnify the employee against the medical service provider collecting payments from the employee that exceed the recommended repriced charge; and
negotiating electronically, by the third party, for the medical service provider to accept the recommended repriced charge as being in accordance with the agreed upon definition of reasonable value for the medical service.