Burnish your value proposition: 5 ways to combat rampant medical overbilling

Overbilling of medical services is running rampant across a benefit broker’s book of business, hidden in plain sight. It’s a national epidemic.

Most group health clients are overbilled millions of dollars every year, and they don’t even know it – nor does their broker of record. These systemic problems worm their way into brow-raising annual renewals for employers and soaring out-of-pocket costs for members, casting a pall over relations with clients and the employee populations served by brokerage or advisory firms.

With frustration continuing to build among customers, no business is safe in a climate that breeds mistrust and dissatisfaction. Consider a recent lawsuit that could spark a troubling trend. This year’s legal action against Johnson & Johnson represents the first alleged ERISA fiduciary duty breach over mismanagement of health plan funds brought by an employee against a major company. And in March of this year The Wall Street Journal reported that it’s now routine for hospitals to add billions of dollars in facility fees for routine care in outpatient centers they own, which is exacerbated by acquisitions and private equity funding.

Egregious medical billing practices serve as a major obstacle to providing accessible and affordable health coverage, running afoul of intensifying government oversight to strengthen a plan’s fiduciary standards. They also undermine the marketplace by souring health plan sponsors on the level of service they’re receiving from health insurance brokers, third-party administrators and other partners.

Mounting financial hardships

JAMA Network Open estimates that medical pricing irregularities, fraud and abuse cost between $289 billion and $324 billion. It’s no wonder that unpaid medical bills are now the leading cause of personal bankruptcy in the U.S. Lawmakers and policymakers have been taking notice, crafting legislative and regulatory remedies for stripping away layers of hidden costs.

In a way, surgeons and hospitals that engage in deliberate overbilling are essentially imposing a phantom tax on every broker’s client base. But it doesn’t have to be this way. In fact, putting an end to these egregious practices is not only possible, in fact it will actually raise a broker’s value proposition across several important areas.

Solutions at hand

Despite this daunting trend, there is a safe path to higher ground that will elevate a brokerage or advisory practice in ways you may have never imagined. What has been sorely needed is a way to transform health care pricing transparency to ‘level the paying’ field for health care payors, providers and patients. Increasingly advanced payment-integrity technology is emerging to combat rampant medical overbilling.

However, it must be paired with expert medical and legal acumen to ensure that every facility bill is reviewed and priced with precision to assure the most fair and accurate payment, and is completely defensible in court.

Experienced physicians and surgeons who understand the medicine behind the charges that are being incurred for medical procedures should be reviewing these bills. They’re in a much better position to spot discrepancies than non-medical coders or administrative personnel who lack their knowledge and are prone to burnout and high turnover. Their expertise in claim review and repricing can shield patients from predatory practices and can save clients millions yearly.

Without their involvement, there is no true payment integrity or hope of ever paying providers fairly. And if the right formula is in place to secure a fair value for medical services, then the health plan sponsor will easily protect itself from litigation.

Stepping lively into success

Having the best possible solutions in place offer brokers and advisors a strategy that will yield exceptional results across five key areas. Consider what ending rampant medical overbilling can accomplish for a brokerage or advisory firm in short order:

1. Significant client savings

As shocking as it may sound, medical bills that exceed justifiable charges by a factor of 10 or even as much as 100 times are commonplace. Bills often run into the hundreds of thousands of dollars, if not millions, when legitimate charges are only a fraction of that. Imagine the impact that ending egregious billing practices can have on bending the cost curve – saving dollars that are so significant they can be reinvested in health benefits coverage, used to ease or eliminate out-of-pocket costs or pumped back into the business in countless other ways.

2. Compliance with the CAA

Rampant medical overbilling is firmly in the crosshairs of the Consolidated Appropriations Act, which lays the groundwork for greater transparency and better stewardship of health and welfare benefits. The CAA serves as a reminder that plan sponsors must act in the best interest of plan participants and their beneficiaries. Ensuring that medical procedures are priced in a fair and reasonable manner helps immeasurably when it comes to compliance with this important law.

3. Improved employee experience

Having to navigate their way through a complex maze of pre-authorizations, paperwork and provider network restrictions is hard enough for health plan members. The same can be said about rising monthly premiums, annual deductibles, co-pays and coinsurance. Add facing egregious or unreasonable costs, as well as balance bills, to the mix and that exacerbates the level of friction employees and their families already face. But when employees are shielded from rampant medical overbilling practices, their health benefits experience will improve right away.

4. Stronger client relations

Given the depth of dysfunction in U.S. health care, benefits brokers are always looking over their shoulder, fearing that at any moment a competitor could swoop in and lure their client away with all sorts of promises. All it takes is for one costly claim to go sideways, and just like that, a door can slam shut on years of sweat equity. Forging long-term relationships is a real challenge in this climate. The best way to safeguard those relations, of course, is to always put clients first. By offering a way out of the medical overbilling morass, brokers will solidify a competitive edge that stabilizes client relations as far as the eye can see.

Related: Walgreens agrees to pay $16 million in Medicaid overbilling lawsuit

5. Strategic growth opportunities

Overbilling stands is a major impediment to client satisfaction at renewal time, as well as building a prosperous brokerage. Helping clients raise the bar on this hot-button issue is a unique differentiator that will distinguish a brokerage/advisory for a competitive edge. It will not only help burnish prospecting for new clients, but also mine new revenue streams and grow a book of business.

Saving employers money on their health benefit costs serves as a gateway to greater client satisfaction. But there are so many other moving parts to achieving success. Compliance with the CAA is now top of mind for health plan sponsors that need to elevate their fiduciary responsibilities. Helping clients combat rampant medical overbilling not only checks those boxes, it also provides an opportunity to improve employee experiences with their health plan, as well as strengthen client relations and grow business.

William R. Mattecheck, CLU, RHU, National Director of Broker Relations, WellRithms