Gets Problems Solved

Benefit: You can avoid the overwhelming bureaucracy which saves you time, money and additional gray hair.

A multi-state manufacturing group of more than 2,000 employees who needed to get a handle on the rising medical insurance costs for both their employees and retirees was referred to us.  This objective was accomplished by consolidating plans, eliminating some carriers, modifying plan designs and, in the case of the retirees, changing carriers altogether.  At the time we engaged with this group they were self-insuring their health plan.

Before we could provide this employer with viable, cost-saving choices, we began a thorough review of their existing benefit offerings and financial arrangements as well as a detailed analysis of language contained in the contract of a reinsurance carrier that had been placed by a previous consultant.  A major finding of our analysis revealed that claims paid for out-of-state prescription drugs had been erroneously excluded from aggregate coverage by the reinsurance carrier.

This discovery set off a series of events that required patience, tenacity and perseverance:

• Challenged reinsurance carrier  with filing time limitation and prescription drug inclusion;
• Requested and obtained multiple reports from BCBSRI to conduct our own aggregate and individual stop loss analysis (reinsurance carrier initially refused to do this);
• Directly corresponded with reinsurance carrier’s president to refute their position that nothing was owed to our client;
• Personally met with reinsurance carrier on three separate occasions to present our findings and request their reconsideration of both the time limitation and inclusion of drugs.

The time, effort and energy expended on behalf of our client were extraordinary.  However, because of our familiarity with this type of plan design and financial arrangement and previous dealings with the carrier, we felt confident that our efforts would not be a lesson in futility.

In the end, the reinsurance carrier overturned their decision regarding the time-filing limitation and agreed to include the disputed drug claims as part of the aggregate coverage. These decisions resulted in our client receiving multiple reimbursements from the reinsurance carrier totaling over $140,000.

It is also important to note that Paradigm Benefits Group never asked for and never received any portion or percentage of these recovered monies.  We simply knew what could and what had to be done and we knew that we had the expertise, the savvy and the reputation to get it done.  And the only thing our client needed to do was cash the check!