#request.oFMSBhv.render(file_name="TPA_Newsletter_header.gif",file_uuid="B71EE477-0782-3D2E-1772-DD1BF1FCF186",file_type="gif",behaviour="Default",src="/shadomx/apps/fms/fmsdownload.cfm?file_uuid=B71EE477-0782-3D2E-1772-DD1BF1FCF186&siteName=prodline",icon="/shadomx/apps/fms/admin/pics/icon_gif.gif",caption="TPA_Newsletter_header.gif",id="B71EE477-0782-3D2E-1772-DD1BF1FCF186",align="left",border="0",width="615",height="125")#May 2009


Inside this Issue:

#request.oFMSBhv.render(file_name="TPA_TreePhoto_200w.jpg",file_uuid="DA04153C-B82F-261E-FCC1-0DE78664F347",file_type="jpg",behaviour="Default",src="/shadomx/apps/fms/fmsdownload.cfm?file_uuid=DA04153C-B82F-261E-FCC1-0DE78664F347&siteName=prodline",icon="/shadomx/apps/fms/admin/pics/icon_jpg.gif",align="right")#SunResources® Tackling Oncology Costs

SunResources is a powerful program that can lower our customers'' claim costs

Did you know that half of all men and one-third of all women in the U.S. will develop cancer during their lifetimes? Today, more than 5 million in the U.S. are living with cancer or have had cancer.1

Cancer is a leading cause of high-dollar claims. Many cancer patients will end up in clinical trials, depending on their diagnosis, and many others will receive bone marrow transplants.

Last year, through SunResources, our Case Management team handled 253 transplant contracts at SunExcel Centers of Excellence. Of those, almost one-third were stem cell or bone marrow transplants. Our average SunExcel discount in 2008 was 44%.2

Our SunResources program helps lower our customers'' claim costs and extend their claimants'' lifetime maximums, making self-funding more affordable for everyone.

What to Know About Eligible Fees

Please remember that when you contract with a third party vendor to provide certain services, you should review their fees to determine if they are eligible expenses according to the plan document and our Stop-Loss policy.

Sun Life''s Stop-Loss policy will reimburse policyholders for certain vendor fees. In fact, we were among the first Stop-Loss insurers to clearly spell out which fees are covered in our contract. We strategically wrote our policy in a clear, simple manner, so customers can understand up front which fees are covered and which are not.

Our 07SL Stop-Loss policy covers these fees as eligible expenses:

  • Hourly case management fees
  • Hospital bill audit fees
  • Access fees for non-directed provider networks
  • Negotiation fees for out-of-network bills

Fees for the following services are not considered eligible expenses: medical reviews, reasonable and customary determinations, consultant fees, PPO access, and cost-containment administration.

When you submit covered fees, we may ask for additional documentation as a routine part of our claim process. If you have any questions, please contact Paul Gatanti at paul.gatanti@sunlife.com.

Claims Spotlight

"Hurry Up, Already" How to Speed Up Your Stop-Loss Claim

Sun Life processes claims in an average of 15 business days

Sun Life Financial receives an average of 300 Stop-Loss claims every week. Although incoming claims are seasonal, with more claim submissions occurring from November to February, we process claims in an average of 15 business days year-round.

When we take longer than 15 days to process a claim, it''s most often because we lack complete documentation. While we try to ask for additional information when we receive the claim, there are times when the missing information isn''t apparent until we dig in and start our in-depth claim review.

What are the most common causes of delayed claims? Here''s our list:

  • Eligibility: We currently have 125 claims that are missing eligibility information. We rely on the administrator for this crucial information, including any changes to eligibility status, such as FMLA, STD, LTD, COBRA, and medical leave of absence as defined in the plan document.
  • Incorrect reimbursement amount: Another common delay occurs when the requested reimbursement amount on the Specific claim form doesn''t match the total paid claims report or the total of all EOBs.
  • Missing current plan document
  • Missing accident information
  • Missing pre-certification report and utilization review report
  • Missing case management notes
  • Missing copies of bills over $25,000 (or as requested to determine eligible expenses): An example is a hospital bill for chemotherapy that does not itemize the chemotherapy drugs, but combines them under revenue code 250-Pharmacy and/or 636-Pharmacy Drug Requiring Detailed Coding.
  • Procedures codes, ICD-9 codes
  • Providers'' names that rendered services

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Using HDI to Help Save Your Clients'' Money

Through our SunResources cost-containment program, Sun Life Financial can become your partner in managing claims. We have an extensive network of preferred vendors who can help lower first-dollar and catastrophic claims. As one of the nation''s largest Stop-Loss providers, we have negotiated preferred pricing that we can pass onto you, on behalf of our mutual customers.

We can help you lower the total cost of your clients'' self-funded plan, rather than just add to it. We''re here to help, even before a Stop-Loss claim occurs.

You can call on us anytime to discuss a claim. If you need hospital bill audit services, please ask about HealthDataInsights (HDI). HDI is a Sun Life Financial preferred vendor for bill audit and negotiation. We have a long history of successfully managing out-of-network negotiations and in- and outpatient hospital bills. Using its sophisticated technology platform developed over the course of more than ten years, HDI identifies undocumented and unsubstantiated charges, selecting bills based on the size of the potential savings and its past experience with hospitals.

Here are some highlights to know about HDI:

  • Website: www.healthdatainsights.com
  • Headquarters in Las Vegas, NV with operations in Newport Beach, CA and Orlando, FL
  • Savings range from 4% to 8% on claims accepted for audit
  • Clinical staff can prescreen your bills for audit at no charge
  • Immediate impact to your bottom line

For more information, please contact Paul Gatanti at SLF (paul.gatanti@sunlife.com or (800) 432-1102, ext. 3920) or Shirley Balsley at HDI at (800) 621-7557, ext. 8037.

Contact Us

Want to speak to us? Feel free to send any general questions or feedback to: tpa.insight@sunlife.com.

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