Matrix RMS is the risk management function that is separately contracted on a fee basis with each medical stop loss client of Matrix Group Benefits. Matrix RMS also contracts independently and separately from Matrix Group Benefits for various projects with networks, medical management firms, TPA’s employers and others.
The primary role of Matrix RMS is to provide facultative oversight of network and medical management services contracted by plan sponsors based on information provided by the contracted service entities. Matrix RMS is limited in its scope to information that it is provided, both in the timeliness of the information as well as the completeness and accuracy of the information. Matrix RMS may assess information and suggest that additional medical cost management interventions may be appropriate to consider and may pose such suggestions to plan consultants, contracted TPA’s and contracted medical management firms. Within this scope of work, Matrix RMS assists in the identification and referral of emerging or ongoing medical claims to specialty resource firms. Matrix RMS also provides assessment of provider networks and their payer-provider contracts and develops impact evaluations for both underwriting and claims management purposes.
Matrix RMS provides assistance with the identification of specialty resource firms and facilitates the referral and coordination of these resources that provide services such as:
- Neonatal case management and bill review, including accuracy of bill, appropriateness of coding and charges, and negotiation of allowable amounts;
- Hemophilia case management and support services including drug acquisition for blood disorders such as hemophilia;
- Review of large hospital bills for accuracy of bill. Appropriateness of coding and charges, and negotiation of allowable amounts and negotiation of patient specific discounts. Reviews of this scope require the UB -92 bill summary, the itemized billing statement and information related to the nature and amount of potential contract adjustments related to PPO’s ;
- Transplant networks for potential organ transplant cases;
- Review of out-of-area and / or out-of-primary-network facility charges based on a Medicare allowable schedule for large hospital bills, requiring form UB-92 including Revenue Codes and itemized bills;
- Oncology case management and support services including chemotherapy drug acquisition for administration in outpatient settings.
- Dialysis management programs that involve amendment of the Plan Document and pre-payment review of all dialysis bills.
Charges for the services provided by these specialty resource companies are paid by the Plan Sponsor as part of the participant’s claim and will be reimbursed by the medical stop loss contract if the benefit amount for the claimant exceeds the specific stop loss deductible amount in the contract of the Plan Sponsor. Matrix RMS has negotiated preferred pricing agreements for its medical stop loss clients with many of the specialty firms to reduce the cost of the services for Plan Sponsors. Matrix RMS makes these firms available to the Plan Sponsor and its contracted service providers to assist the Plan Sponsor in the management of its Plan.