Premature births are one of the leading causes of complications during delivery and continued issues throughout the first days of a newborn’s life. Over the last 3 years, the U.S. pre-term birth rate has increased to 10% of all births. Roundstone recently received a high-dollar claim for a complicated birth and lengthy neonatal ICU hospitalization. The newborn, now a claimant, was born prematurely and suffered difficulties during birth that required long-term care. As newborn and child birth claims go, this was a catastrophic situation.
Due to the strain on the family of the baby being confined to a hospital, the doctor suggested that in-home care may benefit both the baby and the family. Roundstone consulted on the implementation of this strategy, as this type of in-home care was not covered under the employer’s benefits. After reviewing the cost of neonatal ICU stays compared to 24-hour in-home nursing care, Roundstone and the Third-Party Administrator (TPA) determined it was more cost effective to have the child receive care at home. Everyone agreed it was the best plan of action for the infant.
Roundstone, the advisor, the TPA, the employer, and the family collaborated to track down a potential provider. Unfortunately, there was a shortage of nurses in the family’s area. But our nurses did not give up their search. They made calls to several providers trying to piece together a workable solution. After several weeks, the family was able to bring their child home with the benefit of round-the-clock care. The cost savings to both the family and employer health plan were immediate.
While this specific treatment was not included in the plan design, Roundstone worked with the advisor and employer to find a strategy to achieve the family’s wishes and save the group and captive money.
Sources: cdc.gov, cbsnews.com
As a Claims Analyst at Roundstone, I am responsible for monitoring stop loss claims. I verify and update information on claim submissions by reviewing policies and plan documents in order to determine which charges are eligible for reimbursement. I am a graduate of Lorain County Community College with an Associate of Arts degree. I enjoy attending Cleveland sports events in my free time.