Reasonable value medical benefit plan

Abstract

A self-insured or self funded medical benefit plan is provided by an employer wherein the self-insured medical benefit plan is governed by ERISA, and wherein the employer who is providing the medical benefit plan is 100 percent responsible for payment for medical services provided to an employee, receiving the benefit of the medical benefit plan, to a medical service provider for covered medical services and products. The medical benefit plan and method for providing the medical benefit plan determines a reasonable value for the medical services provided by a medical service provider to a participant of the plan, reprices a bill or claim from the medical service provider, and protects the participant/employee under ERISA from attempted collections of additional moneys that a medical service provider may believe is owed for the medical services but were not paid by the exemplary self insured medical benefit plan.

1 . For a Medical Benefit Plan (MBP) established by an employer for the benefit of an employee of the employer, the MBP comprising funds for a payment of medical services provided by a medical service provider to the employee, a method of repricing a medical service provider bill, by a third party, for medical services provided to the employee, the method of repricing the medical service provider bill comprising:
 receiving and storing, by the third party, the medical service provider bill data in a computer system, the medical service provider bill data comprising a description of a medical service, a code for the medical service, and a charge for the medical service;   providing to the MBP, by the computer system, a recommended repriced charge for the medical service being in accordance with an agreed upon definition of reasonable value for the medical service, the recommended repriced charge being based on a mathematical comparison or analysis, performed by the computer system, of a calculated cost-to-charge ratio history, a profit margin history, or a medical service cost database data for a same description of the medical service or a same code for the medical service within a same or similar geographically comparable area, the recommended repriced charge comprising a lower recommended amount for the MBP to pay the medical service provider for the medical service and an explanation of review document; and   negotiating electronically, by the third party with the medical service provider, toward a medical service provider acceptance of the recommended repriced charge as being in accordance with the agreed upon definition of reasonable value for the medical service.   
     
     
         2 . The method of  claim 1 , further comprising:
 checking, by the computer system prior to providing, the medical service provider bill data for a medical service code error.   
     
     
         3 . The method of  claim 1 , wherein the mathematical comparison or analysis of the calculated cost-to-charge ratio history or the profit margin history comprises:
 comparing, by the computer system prior to providing, the medical service bill data with a calculated cost-to-charge ratio history or a calculated profit margin history associated with the medical service provided by the medical service provider.   
     
     
         4 . The method of  claim 3 , further comprising:
 determining, by the computer system, whether the charge for the medical service comprises a cost-to-charge ratio or profit margin that is greater than the calculated cost-to-charge ratio history or calculated profit margin history by a predetermined amount.   
     
     
         5 . The method of  claim 1 , wherein the mathematical comparison or analysis of the medical service cost database data further comprises:
 comparing, by the computer system, the medical service provider bill data with medical service cost database data and determining if the charge for the medical service is within a predetermined range of acceptable charges for a same or similar geographically comparable area.   
     
     
         6 . The method of  claim 1 , wherein the MBP is an an ERISA Medical Benefit Plan (EMBP). 
     
     
         7 . The method of  claim 1 , wherein the recommended repriced charge further comprises appropriate claim denial language or partial claim denial language adapted to indemnify the employee from collection by the medical service provider of additional collections from the employee beyond or above the lower recommended amount. 
     
     
         8 . For a medical benefit plan (MBP) established by an employer for the benefit of an employee of the employer, a method of repricing a medical service provider bill, by a third party, for medical services provided to the employee, the method of repricing the medical service provider bill comprising:
 receiving and storing, by the third party, the medical bill provider bill data in a computer system, the medical service provider bill data comprising a description of the medical service, a code for the medical service, and a charge for the medical service;   performing, within the computer system, a mathematical or comparison analysis of the medical service provider bill data with respect to a calculated cost-to-charge ratio history data, a calculated profit margin history data, or a medical service cost database data for substantially a same description of the medical service or a same code for the medical service within a same or a similar geographically comparable area;   providing, to the MBP by the computer system, a recommended repriced charge for the medical service, based on the performing step, and in accordance with an previously agreed upon definition of reasonable value for the medical service; the recommended repriced charge comprising a lower recommended amount for the MBP to pay the medical service provider for the medical service, and an explanation of review document;   negotiating electronically, by the third party with the medical service provider, toward a medical service provider acceptance of the recommended repriced charge as being in accordance with the previously agreed upon definition of reasonable value for the medical service.   
     
     
         9 . The method of  claim 8 , further comprising checking, by the computer system prior to performing, the medical provider bill data for a medical service code error. 
     
     
         10 . The method of  claim 8 , wherein the MBP is an Employee Retirement Income Security Act (ERISA) Medical Benefit Plan (EMBP). 
     
     
         11 . For a Medical Benefit Plan (MBP) wherein the medical benefit plan is provided via an employer to the benefit of an employee; wherein after the employee receives a medical service from a medical service provider, the MBP is responsible for paying a medical service provider bill for the medical service; a method of repricing the medical service provider bill, by a repricing entity, the method comprising:
 receiving, by the repricing entity, the medical service provider bill, the medical service provider bill comprising a line item information comprising a medical service provider's charge for a service or product, a description of the service or product, and a code for the service or product;   storing the medical service provider bill in a computer system;   comparing, by the computer system, the line item information with data from a plurality of databases accessible electronically by the computer system, wherein at least one of the plurality of databases comprises preexisting-accepted medical service bill data for a same service or product provided by a comparable medical service provider in a same or a similar geographical location as the medical service provider;   determining, by the computer system, a reasonable value for the service or product based, at least in part, on the step of comparing;   providing to the MBP, by the computer system, a recommended repriced charge for the service or product in accordance with an agreed upon definition of reasonable value for the medical service or product, the recommended repriced charge comprises the reasonable value for the service or product for the MBP to pay the medical service provider and an explanation of review; and   negotiating electronically, by the repricing entity with the medical service provider, toward a medical service provider acceptance of the recommended repriced charge as being in accordance with the previously agreed upon definition of reasonable value of the medical service or product.   
     
     
         12 . The method of  claim 11 , wherein the reasonable value for the service or product is less than the medical service provider's charge for the service or product. 
     
     
         13 . The method of  claim 11 , wherein the recommended repriced charge further comprises appropriate claim denial language or partial claim denial language adapted to indemnify the employee from a collection by the medical service provider that is in addition to the recommended repriced charge.