Benefits professionals can help employers with self-funded plans fight the abuse to watching for three important red flags.

1. Assistant surgeons charging at primary surgeon rates

In surgical procedures, it's a standard industry practice for an assistant surgeon to receive only 16% to 20% of the primary surgeon's fee.

However, many claims reveal that assistant surgeons are billing at rates far beyond this threshold. In some cases, they're nearly matching the primary surgeon's charges.

Assistant surgeon charges should be flagged and adjusted if they exceed 20% of the primary surgeon's fee.

Claim review teams should be trained to apply industry-standard reductions before payments are processed. Additionally, direct negotiation with providers can help challenge these inflated charges, ensuring that self-funded employers pay only what is fair and reasonable.

2. Missing discounts multiple-procedure discounts

When multiple cardiology procedures are performed during the same surgical session, standard industry guidelines require secondary procedures to be billed at a 50% discount.

This reduction accounts for the overlap in resources and time, ensuring fair and reasonable reimbursement.

However, many providers fail to apply this discount, instead billing every procedure at full price to maximize their reimbursement — at the direct expense of employers and their health plans.

Every claim involving multiple procedures should be carefully reviewed to ensure the 50% reduction is correctly applied. And here, too, direct negotiations can defend employers against excessive charges.

3. Bundling Manipulation

For many surgical procedures, some services and equipment should already be included the cost of the primary cost and should not be billed separately.

For example, the use of an operating microscope in cardiovascular procedures is considered incidental to the surgery itself.

However, some providers unbundle these charges, billing them separately to increase reimbursement

Claim review teams can be trained to watch for this problem and compare the actual billing with national coding benchmarks.

For brokers, TPAs and stop-loss managers, managing high-cost claims carefully is not just about reducing expenses: It's about upholding fiduciary responsibility and ensuring the long-term financial sustainability of self-funded health care plans.

Every inflated cardiology claim that goes unchallenged contributes to rising employer health care costs, higher stop-loss renewals and increased financial strain on self-insured plans.

Bruce D. Roffé is the president and CEO of H.H.C Group, a health care consulting firm that provides cost-containment services for insurers and state entities. It operates in New York as a dispute resolution entity under the No Surprises Act.