How it Works

Concierge-level customer service

A superior member experience is delivered to all Claim Watcher members through our Concierge Team. Concierge services include assistance with finding a provider, outreach to physicians, answering any questions regarding member health benefits, and more. This high level of assistance keeps things simple for our members.

Claims auditing and repricing

Our audit team of nurses and certified health professionals reviews charges line-by-line for accuracy and appropriateness on all facility claims.

Our expert staff is experienced in medical coding guidelines and regulations, including compliance and reimbursement, allowing for effective handling of claim issues such as:

  • Billing errors
  • Bundling issues
  • Upcoding of Diagnostic Related Groups
  • Unexplainable charges
  • Diagnosis/procedure billing reviews.

They work in conjunction with our proprietary cloud-based algorithm to correct inaccuracies. Our reference-based pricing (RBP) methodology offers a combination of exclusive and industry-standard methods, and ensures claims are reviewed and corrected prior to any payment being made.

RBP is a data-driven reimbursement methodology that uses actual cost data and Medicare rates from Centers for Medicare & Medicaid Services to determine a fair and reasonable payment for medical care.

This approach replaces paying discounts off of arbitrary, inflated charges with a fair and transparent method of paying the higher of a percentage above actual costs or a percent above Medicare. Our goal is to strike the right balance between the actual provider costs and a fair margin above that cost to facilitate a sustainable relationship with providers. This method has shown significant claim savings and an acceptance rate of 98% by medical providers.

In addition to significant savings, Reference-Based Pricing takes control away from health insurance companies, and gives that control back to employers

Out-of-network solutions

Claim Watcher may be used as a full replacement of major carriers or as a protection against out-of-network surprise bills. With traditional insurance carriers, out-of-network claims typically happen when a member is traveling and requires emergency care, but can also occur at a local facility if a particular service  is not covered. These claims can account for up to 8% of a health plan’s spend. For out-of-network claims, our team performs a full audit and repricing, and provides a full legal defense against balance bills.

Direct provider contracting

We partner directly with a healthcare provider or health system to ensure quality options and gain more control over employee health benefit design. We currently have partnerships with top-ranked and widely recognized institutions, such as Penn Medicine in the greater Philadelphia region. This further reduces the possibility of a balance bill, and provides lower costs for quality care compared to the offerings of a traditional PPO network.

Our direct contracts:

  • are typically based on a percentage of Medicare reimbursement, not a discount off billed charges
  • can lower the cost of care and improve health outcomes
  • can provide more cost-effective solutions that eliminate member cost-sharing
  • can be full service contracts for all members or single-patient agreements with providers.

Medical management

Claim Watcher-backed plans proactively work with medical management and PBM partners to encourage preventive care and actively monitor chronic conditions so that members access appropriate levels of care to address small issues before they become large ones.

This approach:

  • Prevents high-dollar claims that result from avoidable hospitalizations, surgeries, and other inpatient services
  • Prevents high-dollar and chronic claim submissions that result from avoidable conditions
  • Ensures members can access the care they need without incentivizing unnecessary care
  • Keeps members healthier – which means members miss fewer work days and are more productive
  • Allows medical management to determine medical necessity and appropriateness of care
  • Controls the sourcing and cost of high-cost chemotherapy, infusion, and specialty drugs.