Sample Cost Savings for
Medical Benefits Insurer
Claim Cost Benefit Savings
Per 100 claims reviewed: Cost of Review $24,000.00
Average denial rate of 82%: Benefit Savings $1,400,000.00
NET SAVINGS: $1,400,000/100 CLAIMS.
Based on a claims volume of 100 claims per year, the Cost/Benefit return is 56:1. Higher volume of submitted claims will create even greater savings and a higher Cost/Benefit return. This figure includes a combination of Orthognathic, TMJ, Dental Implant, and other Oral and Maxillofacial surgical procedures. The benefit number includes surgeon's fees, hospital costs, and ancillary fees such as anesthesiologist, implant and graft materials, and laboratory charges.
Doctor presents preauthorization letter with documentation for double jaw orthognathic surgery, claiming the surgery to be medically necessary due to functional deficiency impacting on mastication and speech patterns. He denies there will be cosmetic gain. Analysis of the claim reveals no medical necessity with the primary reason for the surgery being correction of malocclusion and cosmetic improvement.
Surgical fees: $9,000-11,000
Hospital fees: $20,000-40,000
Ancillary fees: $1000-2000 (anesthesiologist, miscellaneous supplies, etc.)
Cost savings based on denial of unnecessary surgery: $29,000-51,000.
Doctor presents preauthorization letter for internal derangements of TMJ, bilaterally. Documentation may include MRI report and state the need for surgery to correct problem. Analysis of case shows no conservative treatment modes have been tried first and there is no published scientifically valid research to indicate the surgical procedure is the correct one or will resolve the problem. Additionally, it will be noted that doing the procedure will increase the liklihood of future surgery on the joints.
Surgery fees: $9000-11,000
Hospital fees: $11,000-$15,000
Ancillary fees: $1000-$8000 (artificial joints, alloplastic materials, anesthesiologist, miscellaneous supplies, etc)
Cost savings based on denial of undocumented claim not utilizing conservative methods: $21,000-$34,000.
Dental Implant Surgery
Doctor presents preauthorization for medically necessary dental implants with x-rays and pertinent history. Analysis shows the patient will have more than the necessary number of implants needed and expensive fixed bridgework which is not medically necessary but is for the patient's cosmetic benefit. Medical necessity may be documented but addressed with a less expensive adequate procedure.
Surgery fees: $12,000
Prosthetic fees: $9800
Ancillary fees: $1500 (splint, alloplastic graft, lab fees)
Cost savings based on denial for lack of legitimate medical necessity: $23,000.