Unlocking Post Claim Adjudication: Insights with Jordan Hersh

In this episode of ShiftShapers, host David explores the complex world of post claim adjudication with Jordan Hersh, Vice President of Enterprise Solutions at Vālenz. They discuss the intricacies of self-funded plans, reference-based pricing, and the potential savings associated with renegotiating out-of-network claims. The conversation delves into high performance networks, the inverse relationship between cost and quality in healthcare, and methods for improving transparency and cost containment. Learn about the strategies that can lead to significant cost savings while maintaining high-quality care.

In This Episode:

00:00 Introduction to Post Claim Adjudication

00:34 Meet Jordan Hirsch from Vālenz

01:29 Understanding Post Claim Work

02:13 Reference Based Pricing: Pros and Cons

03:55 Narrow Networks vs High Performance Networks

08:14 Out of Network Claims and Cost Containment

15:23 Transparency in Medical Care Costs and Quality

17:18 Incentives for Care Coordination

18:28 Wrapping Up: Savings and Final Thoughts

Quotes:

“Readmission rates, complication rates, mortality rates, we’re taking that into account and making sure that when people do people stay in-network or go to the panel of those high-performance network partners, they’re getting top tier coverage.”

“Depending on the primary PPO network regardless of broad network or network of concise nature, there’s going to be out-of-network medical claims. And that can cost self-funded plans a lot of money if it’s not managed correctly.”

“Some plans we’ve seen pay out-of-network claims at full bill charges, some take a usual customary approach. Having a much more direct and aggressive approach can really be a game-changer for self-funded plans and materially impact the bottom line.”

“So being able to achieve a discount, that can also assure them that they’re going to be paid and have a little bit more clarity on how the member responsibly can be split up. Oftentimes we see self-funded plans offering some type of incentive.”

“So a plan with a medical spend with a million dollars, implementing these types of tools into the right education training to the members, could reduce their overall medical spend by about 25%.”