Stop Loss Claims

• The Claim: $349K billed amount with a 37% PPO discount of $129K.
• Claim after PPO discount: $220K.
• Claim Administrator reached out to us requesting an audit of the claim.
• Claim review and negotiation was put in place, with findings of $124K in excessive billing for implants.
• The Plan's total liability after negotiation was further reduced by $78K to $142K.

The Result: Union Labor Life facilitated a 59% price reduction, saving the Plan $207,000 on this claim!

• The Claim: $833K billed amount with a 15% PPO discount.
• Claim after PPO discount: $708K.
• Claim Administrator reached out to us requesting Advanced Funding due to high dollar amount of this claim.
• Claim negotiation achieved an additional 15% discount, increasing the total discount rate to 30%.
• The Plan's total liability after negotiation was $583K.

The Result: Union Labor Life help the Plan save $250,000!

• The Claim: High dollar IVIG (Hizentra) Therapy for Immunodeficiency is paid through the Plan's PMB.
• Weekly Prophylactic charges: $28,332.90.
• Discount through PBM Negotiation: $9,066.53 (32%).
• Weekly Cost to the Plan: $19,266.7.
• Annualized Cost to the Plan: $1,001,868.40.
• Union Labor Life facilitated negotiation on this and all future claims, using Average Dispensing cost as basis.
• Supplier agreed to accept 25% of billed amount reducing the weekly cost to $7,083.
• New Annualized cost: $368,327.70 for prophylactic care.

The Result: Union Labor Life helped the Plan save $633,500 per year!

• The Claim: Non-participating SurgiCenter billed:
  


      $432K for the facility
  +  $330K for the surgeon fees
      $762 Total Amount

• Prior to payment, the Plan requested our assistance because the facility was unwilling to reduce its bills.
• Bill review found claims to be extremely over the Usual & Customary (UCR).
• The facility was advised of our findings and the bills were reduced by 86.5% to $103K!

The Result: Union Labor Life helped the Plan save $649,000!

• The Claim: TPA paid $1,240,712 to the Plan's PBM for billed specialty drug treatment and then submitted claim to Union Labor Life (ULL).
• Specific Deductible: $220,000.
• Total Reimbursement Amount Requested: $1,020,712.
• After bill review by ULL staff, ULL found a billing/payment error to the PBM, where the decimal points were not on the right places. ULL advised the TPA, who in turn disputed the claim with the PBM. PBM agreed with our findings.
• Final Amount paid by the Fund for the claim: $12,500; a 99% reduction!

The Result: Union Labor Life helped save claim dollars!

• TPA recovered $1,228,212 from the PBM;
• Better Plan loss experience with no Stop Loss claim.