I am currently dealing with a TPA in NY, that negotiated the reinsurance with an A+ rated reinsurer. To remove the pre-cert for in patient hospital, my client is being chrged an additional $18,000. We never had pre-cert before and now are being penalized for not taking it. Any advices or suggestions

robkt

This is just my opinion based on medical plan design, but the underwriter must be assuming that there is a perceived additional risk that their exposure to higher inpatient hospital expenses will occur. Without pre cert a person may have an inpatient procedure performed when in fact the procedure may be done on an outpatient bases at a lower cost.

However, having said this I’m not sure about the justification for the additional $18,000. Have the stop loss carrier explain the rational for the additional cost. If there is sufficient outpatient and inpatient claims experience they should be able to explain their reasoning, or not.

What is the rationale for stating that you are now being penalized?

The fact that you are being charged an additional $ 18,000 for a fairly standard procedure that is expected to help in controlling unnecessary usage and costs has nothing to do with whether or not you had it before or believe that you did not have it.

$18,000 might also be a low charge because you did not state how many covered lives.