Tom's Take Blog
January 12, 2016
What are peer independent claim reviews and when are they needed?
Tom’s Take: Let’s back up for a minute. One of the ways that self-funded health plans administered through Cypress differ from many fully insured plans traditional carriers offer is the thorough review process health claims go through. We don’t just take a quick process-and-pay approach; rather, we fully scrutinize claim charges on a line-by-line basis.
There are several checks along the way, and our Argus Claim Review team will often come across questionable items as bills are examined. Say, for example, we find a big-ticket testing procedure that doesn’t appear to be medically necessary based on other factors within the scope of the claim. This is typically the point where an investigation begins and a peer independent claim review comes in.
Cypress contracts with multiple URAC-accredited independent reviewers across many fields who are experts in certain specialties such as neurology and cardiology. These professionals will analyze the health claims/files under investigation, consider the plan language and documentation in place and substantiate Argus findings in writing where appropriate.
These peer reviews frequently come into play when medical claims have been denied and subsequently appealed. They are very valuable in that they provide perspective from someone who knows the intricacies of specific medical conditions.
When Cypress responds with peer review results from experts, the associated claim charges are often dropped or reduced. These independent reviews are just one more way Cypress is working to save money on behalf of our employer-clients.