Summary
This case study details the process undertaken by Vālenz® Health in response to a stop loss claim received from a third-party administrator for an inpatient claim totaling $192,498. The TPA requested a second review of the claim after a prescreen by the vendor identified potential savings. Vālenz's expert coding and clinical review team, supported by AI, conducted a thorough line-by-line bill review and requested medical records, which revealed additional savings opportunities. The stop loss company permitted Vālenz to manage the claim due to the higher savings identified and lower fees compared to the initial vendor. The results indicated a 23.8% savings above the PPO discount, and the fee charged to the stop loss company was 6% less than that of the prior vendor. The Valenz team efficiently secured provider signoff within two hours, ensuring no balance billing to the patient and achieving significant savings for the payer.
