Life Cycle of a Claim

December 19, 2022 Sue Riordan

Whether you’re an employer or a member, you might wonder what happens to a health care claim once it’s submitted. Luckily, at Meritain Health®, claims handling is something we know a lot about. So, when it comes to the life cycle of a claim, here’s what you can expect to see.

We focus on timely handling of claims, but also have upfront claims editing practices to help with managing costs. In fact, we have a cost management strategy for most claim situations, including in-network, out-of-network, high-dollar, complex, pharmacy, fraud, waste and abuse, and dialysis claims.

Our strategic approach is how we proactively look for savings. Here’s a look at how it works.

Initial claims review

When we first receive a claim—either electronically, by paper or manually—an initial review is always performed. This helps us determine validity of the claim, considering things like:

- Is the member eligible for services on the claim?
- Is it a duplicate claim?
- Does the claim date fall within the right effective dates for the employer group?

Then, claims are evaluated, adjudicated or repriced, if necessary, and savings are applied. Additionally, strategic in-house claims editing processes are applied using proprietary claims editing software. Our rule sets are designed to stay current with the market and provide deeper support for the changing complexity of self-funded plans.

Cost management strategies

To obtain the most cost-effective pricing on behalf of our clients, we utilize specific cost management strategies in the claims process. In addition, proactive review helps our clients address claims issues and take control of their benefits spending.

What strategies do we employ? This may depend on the amount of the claim and network terms. However, we have processes tailored to high-dollar claims, plus in-network versus out-of-network. For instance, in-network claims over $15,000^*, as well as out-of-network claims over $15,000 are subject to a line-by-line review to capture additional edits, or savings recommendations. An audit process on paid claims is also used to catch errors and maximize savings.

Here are some results we’ve produced:

- Savings are captured on approximately 91 percent of out-of-network claims, with an average savings of 61 percent.
- Meritain Health clients saved nearly $605 million on out-of-network claims in 2021—a 25 percent increase from 2020.
- For claims over $15,000, our high-cost claim protection program delivers an average savings of 67 percent.