By Linda Chase, BA, RNC, CCM
Medical Risk Consultant for Symetra Life Insurance Co.
On December 23, 2006, while on Christmas break from college and just five days before his 19th birthday, John’s car crossed the center lane resulting in a serious motor vehicle accident. John, whose name has been changed to protect his privacy, sustained multiple internal injuries and had a lengthy and complicated hospital stay. He underwent multiple surgeries, was placed on a ventilator and his kidneys failed, requiring life sustaining dialysis. His initial hospitalization was 15 days, with two subsequent admissions; one lasting a month and another 12-day confinement several months later.
A Go-To Company
Symetra Life Insurance Company (Symetra) was the stop loss insurance provider for the employer whose medical plan covered John. A nurse case manager from the TPA administering the medical plan contacted a Symetra medical risk consultant (MRC) nurse to provide notification of a potential large claim.
Knowing the extent of the patient’s injuries and expecting high dollars would be charged by the hospital, the MRC obtained the billed charge information which, after a 10-day stay, had already exceeded half a million dollars. Although John’s medical plan had a 19 percent Preferred Provider Discount (PPO discount), given the extraordinary circumstances of the case, Symetra’s MRC knew that John’s limited lifetime maximum insurance dollars of $2 million under the medical plan would be exhausted in no time.
With this concern in mind, the MRC immediately contacted the Director of Patient Services at the hospital in an attempt to obtain a deeper discount for the employer’s medical plan. After conferencing with the MRC, the hospital agreed to accept 60 percent of billed charges (an additional 21 percent above the PPO discount for a total discount of 40 percent) in exchange for prompt payment by the plan. The MRC worked closely with claims staff at both the employer’s TPA and Symetra to provide prompt funding of the claim.
As of December 2007, total billed charges had exceeded $2.5 million. But as a result of Symetra’s involvement, total lifetime maximum benefits paid were $1.5 million, thus extending John’s lifetime maximum by half a million dollars.
Going Above and Beyond
John’s case was additionally complicated by his medical plan’s wording for continued coverage after age 19, which stated that in order to remain on the plan, the student must remain enrolled the following semester. This was not possible for John due to the extent and severity of his injuries, meaning that John’s medical plan coverage would be terminated or his family would have to elect COBRA for continuation of coverage with average premiums of $400 per month.
Knowing this would cause additional hardship for John’s family, the Symetra MRC scrutinized the medical plan wording looking for ways the employer could continue his coverage. After reviewing the plan, the MRC suggested continued coverage was available for John under the plan’s "Handicapped Dependents" verbiage, which stated that coverage would be available beyond age 19 if child was disabled before his or her 19th birthday. The MRC assisted and advised the TPA claims office on obtaining the necessary documentation for John to be eligible under this plan provision. Thus, the family did not have to pay the additional $400 per month out of pocket to continue coverage under the employer’s medical plan.
A Win-Win for All
Today, John is doing very well and on the road to a full recovery. He is back attending school fulltime and is even working part time. As a result of Symetra’s negotiations on behalf of the employer’s medical plan, John’s health benefits were extended by half a million dollars, allowing him to continue to receive the highest quality healthcare.
Additionally, Symetra’s expertise in plan language and review saved John’s family approximately $5,000 a year in COBRA premiums, and the hospital discount negotiated by the MRC resulted in lowering the employer’s overall health care expenditures and experience ratings.
In a note to Symetra, the TPA’s claims office said, "It has been a privilege to work with you on this challenging case. I can appreciate all your hard work and endeavors to help maximize his lifetime benefit...He surely would have exhausted his lifetime max without your savvy negotiations…It’s been wonderful working with you on this case."
To learn more about Symetra’s stop loss services and our medical risk consultant team, visit us online, contact your regional manager  , or call our home office toll free at 1-800-426-7784.
Linda Chase, BA, RNC, CCM, is a medical risk consultant (MRC) for Symetra Financial. She has more than 25 years combined experience in the medical field and health insurance industry and holds degrees in Nursing and Business Administration. As an MRC at Symetra, Linda oversees the management of ongoing catastrophic medical circumstances, and works with underwriters in the risk assessment process for new and renewal business. She acts as a liaison between TPAs and our partner vendors’ managed-care programs.
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