Wednesday, August 26, 2009

R & C (Reasonable & Customary) Plan Document Language - Real Way to Save Employer $

In an effort to control and limit excessive hospital mark ups of costs and drugs, AMF has begun encouraging health care advisers and administrators to implement reasonable and customary language for both PPO and out-of-network services.

Our newest business partner, NCN (see website) maintains a database of hospital costs throughout the U.S. These costs are those reported to Medicare (CMS). When a plan is willing to pay 120-140% of costs, (a savings over most PPOs) it is difficult for the medical facility to prove that they should be paid more.

To remove the employee from a "balance billing" dispute, AMF is willing to fight on behalf of the employee and to reimburse the facility for charges above R & C if we decide it is not worthwhile to continue denying excess charges!!

As a recent example, AMF recently received a claim from a hospital totaling $542,954.13. With Reasonable & Customary language in the plan document AMF successfully reduced the cost of the claim by 50% saving the employer $271,477!!

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