High dollar surgery claims review program

GHI is committed to employing every means available to help ensure that your group’s premium dollars are spent appropriately. In keeping with that philosophy, by summer 2008 GHI will be implementing a special claims review program for the physician component of high-dollar surgeries. Administered by an independent company, this program will identify and provide focused reviews of aggressive and fraudulent billing that cannot be detected by standard claims edit software.

GHI's High-Cost Surgery Claims Review Program will focus on claims submitted by GHI network musculoskeletal providers, including orthopedic surgeons, neurosurgeons, neurologists, podiatrists, and physiatrists. The program will target all surgery claims in these specialties that exceed the allowed dollar threshold of $5,000 for spinal or back surgeries and $1,250 for all other surgeries.

Qualifying claims will be reviewed by like-specialty Board Certified Medical Directors to ensure that they are supported by the clinical documentation and that the correct coding guidelines are applied. Your group members will be held harmless in this process.

Scheduled for implementation mid-year 2008, GHI's High-Cost Surgery Claims Review Program will be available to insured groups. It will also be offered to ASO and minimum premium groups upon special arrangement. To find out more about how this new program will help your group control claim costs, contact your GHI Account Executive.