What our Team did to Help an Employer and Captive Save Over $150,000
by Gordana Cecez, BSN, RN

A group member underwent a simple outpatient procedure due to a fracture. After the provider submitted its bill, the employer raised a concern regarding the cost of the procedure.  The employer believed the procedure should have cost significantly less than the $183,000 which was still due after the 50% out of network discount was applied.  Though the discount was significant, it was the markup of the charges that caught the employer's attention. 

As the Cost Containment Nurse, I reviewed the charges and confirmed that they were excessive for such an uncomplicated procedure.  My team and I worked closely with the TPA, advisor, and employer throughout the process to contest these excessive charges.  Roundstone engaged an independent auditor to review the charges for usual, customary, and reasonable (UCR) for this type of procedure.  The auditor supplied us with documentation supporting the denial of excessive charges.  As a result, Roundstone backed up the employer and contested the charges. 

After several months of back and forth, the employer’s plan only paid $33,000 for the procedure. The employer and captive saved over $150,000. 

If you have any questions or would like to learn more about our cost containment strategies, please feel free to contact me at gcecez@roundstoneinsurance.com or 440-617-0333. You can also visit our website for more information RoundstoneInsurance.com.

 


My name is Gordana Cecez. I am a graduate of Ursuline College with a degree in Science in Nursing. Prior to joining Roundstone, I was employed as a level 1 trauma nurse in the only trauma unit in the area at the time. My medical background also includes experience in hospice and palliative care. As a cost containment nurse at Roundstone, I work directly with both the underwriting and claims departments. Some of my responsibilities include reviewing complicated high dollar claims to ensure costs are appropriate. I also use my medical background and current resources to target future catastrophic claims for underwriting. I have implemented many companywide processes to facilitate our strategy of planning ahead to ultimately save the employer and captive money. The best part of my job is working for a company who believes in transparency and client advocacy.

 


Roundstone Management, LTD | 15422 Detroit Avenue, Lakewood, OH 44107 | 440.617.0333 | info@roundstoneinsurance.com | roundstoneinsurance.com