Through our Navigator program, we offer specialty services and solutions that help to protect our clients from the financial losses associated with catastrophic medical expenses. To achieve this, we bring together resources designed to complement existing audits and controls without taking over the management of a clinical case or disrupting the timely adjudication of a claim.

High Cost Triggers

When intervention takes place early in cases where excessive medical expenses could result, successful cost management can be implemented to reduce the financial impact on the plan. We work with our clients to develop awareness of the signs of potential high cost scenarios so that they can contact us and implement one of our Navigator services to help protect their bottom line from the financial impact of catastrophic health care costs.

Scenarios Prompting Intervention

  • Neonates 26 weeks or less
  • Complex transplants including multi-visceral or pediatric cases
  • Hemophiliacs
  • Out-of-area catastrophic claims
  • Complex cancer cases including pediatric patients
  • Accidents and trauma
  • Dialysis
  • Use of high-cost specialty pharmaceuticals
  • Claims expected to exceed the reinsurance retention

Services Offered through Navigator

Catastrophic claims management often requires a multi-disciplined methodology. Using a clinically based approach to financial management, we can implement Navigator services to assist in a wide array of situations. Our Navigator program supports the specific needs of each client – before and after a claim is presented for payment.

Core Program Offerings

  • Negotiation for single cases or out-of-area claims
  • Independent audits of financial payment accuracy, medical necessity and treatment protocols
  • High-cost case review, including clinical necessity assessment
  • Review of specialty pharmacy dosing and supplies (evaluation of number of units, cost of units, etc.)
  • Introduction of or evaluation of transplant networks
  • Subrogation services addressing fraud, waste and abuse

The Bottom Line

Our medical risk consultants connect with our clients’ financial and clinical experts – CFOs, risk managers and nurse case managers – to discuss each situation and provide suggestions and solutions that can help to improve outcomes and manage costs. Should a Navigator resource result in a reinsurance recovery, RBS Re will reimburse the cost associated with the audit or negotiation as part of our claims reimbursement.

Contact Us

Lisa Vogler, RN, BSN, CCTC, clinical risk specialist, at 412.544.4811 or to learn more.