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Medical Plan Administration

Leading Edge works with the largest pool of national and regional networks, so you can select the best cross section of most providers in your area and the deepest discounts.

No TPA is more vigilant at containing your costs.

Leading Edge protects your interests and bottom line with the industry’s most sophisticated, automated system that adjudicates,
then double checks claims for both plan compliance and provider fraud, waste, abuse and error.

Here’s how we do it

We don’t just review primary diagnosis codes for accuracy, we review secondary and tertiary codes as well.

Our experience has shown that more times than you might expect, the real diagnosis is not the one listed as the primary diagnosis, which can be a substantially more expensive charge. Investigating additional information from secondary and tertiary diagnoses can determine whether the diagnosis provided matches the actual cause of the medical service received.

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Challenge:

Ask any TPA you are considering if they audit for all second and third diagnosis codes.

Leading Edge Double-Check Audit Engine™

Leading Edge is the only TPA with claims auditing baked right into the system. Our process automatically adjudicates claims, while a separate system checks each claim for plan compliance, as well as provider fraud, waste, abuse and error (FWA&E). It sniffs out errors and ‘creative billing’ practices, and makes sure your claims  payments match any changes to your plan.

We review every emergency room visit.

Emergency room visits are the most expensive kind of care. And many times an emergency room visit is not warranted (for example, for flu shots). Our research shows that up to 20% of emergency room claims could and should have been treated at a doctor’s office or an urgent care facility.

The industry’s most experienced analysts.

Our analysts are trained experts whose job is solely to run the adjudication and audit process for each client and to analyze claims for such issues as inaccuracies and ‘creative billing’. A large percentage of these analyzed claims lead to significant cost containment.

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The analyst assigned to a company’s plan is knowledgeable in its every detail, as well as the ever-changing details of the Affordable Care Act. Our analysts have a deep knowledge of medical treatments and pharmacology. When they spot a potential issue or savings, they aggressively challenge provider and hospital charges on your behalf. Our analysts will take an issue right up to the head of a hospital, if need be.

Short Case Studies:

Same treatment, very different costs.

We’re constantly monitoring medical claims and offering potential cost savings. A client in Utah found itself in the unusual situation of having four employees on dialysis. The cost to the employer was astronomical. We went to work and contacted dialysis providers in the region. We identified two well-respected providers that offered the same dialysis treatment for much less. We negotiated a rate that would save the company 20% in costs.

We audit every single claim before it’s paid.

Very few TPA’s audit their claims in-house. Instead, they employ an outside auditing firm. There are three significant problems with this that you should know:

  • Most audit services review for corrections after claims are paid. This review is usually only a randomized sample audit, which often translates into inaccuracies, missed questionable billing, and over-billing.

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  • Auditing after payment means tracking down medical providers after the fact (called ‘pay and chase’). Chasing after a provider often leads to delays in claim reimbursements, which does not make for a happy employee.
  • When your TPA hires an outside auditor it usually translates into an extra fee for you.

Challenge: Ask any TPA you are considering if they perform in-house auditing or use a third party, and how those costs are passed on to you.

We speak your language

Leading Edge Administrators was born in New York City, a culture of many nationalities and many languages. LEA has strong support in multiple languages

So when we designed our customer support team, we made sure we hired in many languages. Today, we have the strongest language support team of any TPA in the industry. We’re supported by the most advanced real-time translation technology available. And Leading Edge does not just offer phone support, we translate all key documents into any language needed.

Member advocacy

Leading Edge can also offer advocacy services for your members, to negotiate with medical providers and reach out to financial support divisions of pharmaceutical companies. In the rare event that a member exhausts his or her resources, we work closely with services that advocate on their behalf to help them pay down a financial obligation.

Specialized Services

Leading Edge provides and administers all the latest benefit services, including:

  • Audiology testing
  • 24-hour telemedicine for non-emergency issues
  • Sleep apnea testing and treatment

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  • Hearing Aids
  • Wellness programs (Maternity management, disease management)
  • Diabetes management
  • Discount Dental Products
  • Short Term Disability
  • Mobile Immunizations