Integrated Claims Advocacy
Support for the Entire Healthcare Journey
Claims Advocacy saves you time and offers peace of mind knowing your employees are getting the help they need with billing concerns—and learning valuable healthcare consumerism skills in the process. The entire ConsumerMedical Ally Team works together to make sure employees receive the right support at the right time.
You and Your Employees Have an Ally to Help with Billing Errors and Concerns
Confidential, independent support and peace of mind
Simple clarification of coverage and benefits, EOBs and medical bills
Potential cost savings due to increased accuracy of coverage and billing
The Claims Advocacy Experience
We save employees valuable time and reduce stress, allowing them to focus on their jobs, families and health/recovery. The service is structured, yet simple and includes:
Consent to share PHI
Collection and review of bills and statements
Research and calls to health plans and providers
Assistance understanding the appeals process
Regular status updates for the employee
Documentation of case details and decisions
Analytics and Targeted Outreach
ConsumerMedical partners with a leading actuarial firm to offer sophisticated data analytics allowing us to identify and proactively engage employees with certain conditions or risks. Predictive Outreach predicts the likelihood that employees will elect to have any of the procedures covered in our Surgery Decision Support program. Targeted Outreach identifies employees diagnosed with or likely to be diagnosed with a high-cost condition, such as cancer. We then apply a multi-channel outreach approach to encourage engagement.
Predictive Outreach ™
Put Your Claims Data to Work
With Predictive Outreach, we analyze your claims data to identify and rank those who are most at risk for having any of these surgical procedures targeted in our Surgery Decision Support program in the near future:
Hip and knee replacement
Lower back surgery
Weight loss surgery
We leverage a sophisticated predictive algorithm that utilizes approximately 100 distinct variables representing demographic data and thousands of diagnoses and procedures. After ranking the individuals according to risk and intervention opportunity, we conduct targeted outreach to drive engagement in our Surgery Decision Support program.
Predictive Outreach is available to any size employer that purchases our Surgery Decision Support program. Clients must:
Provide two years of medical and pharmacy claims data
Provide monthly eligibility and claims files
Use our data warehouse or provide remote access to theirs
Employers can expect that 2.58% of their
population will have one of these surgeries each year.
With Predictive Outreach, we can reach
about 50% before surgery occurs.
High Cost Conditions – Cancer Quality Program
Support Employees Who Need It Most
ConsumerMedical’s Cancer Quality Program specifically targets individuals who have been diagnosed with cancer or are potentially on the path to a cancer diagnosis. Our sophisticated algorithm—developed with a leading actuarial partner and our clinical experts—allows us to identify and reach the right people at the right time, when initial treatment decisions are being made.
Proactive, multi-channel outreach to identified individuals on a monthly basis
Monetary incentive administered and funded by ConsumerMedical
Specialized oncology decision support built on the 5 Drivers of QUALITY CARE
Delivered by a Medical Ally team that includes an oncologist and oncology nurse
Purchase of Ally Complete Support solution required; Claims Advocacy recommended
Monthly medical and pharmacy claims data
Use of ConsumerMedical’s data warehouse or remote access to employer data warehouse
Cancer accounts for 12% of total medical
costs for U.S. employers. Reaching patients at the right
time is critical to ensuring they receive high-quality,
evidence-based care from the start.
Claims-Based Savings Analysis
Accurate ROI – Guaranteed Savings
You expect a return on your investment in employee healthcare benefits. With Claims-Based Savings from ConsumerMedical, you’ll get a complete and accurate view of cost savings based on actual claims data along with a 1:1 ROI guarantee, so you’ll never invest more than you save.
Claims-Based Savings is available to any size employer that purchases Surgery Decision Support and can provide:
Two years of medical and pharmacy claims data
Monthly eligibility files
Claims data warehouse (use your own or work with our partner)
ConsumerMedical works with leading data
analytics partners and tools to develop and refine
the most accurate model for evaluating
Surgery Decision Support ROI.
For the 1:1 ROI guarantee, a minimum number of participants in Surgery Decision Support is necessary. We also require a minimum of two employee home mailings per program year as well as a minimum number of onsite events. (We use these and other tactics to drive engagement into Surgery Decision Support.)