News & Case Studies

Summit Financial Group (SFG) is dedicated to bringing you "News" in the form of SFG industry Newsletters. See our home page section entitled "Spotlight Feature". If you would like to receive our free monthly newsletter please send an e-mail entitled "Please send me your Newsletter" to Shannon@yoursummit.com .

With over 600 corporate clients we frequently have opportunities to come along side clients to help them "fix" some rather sticky situations with some rather dramatic results. We often record these successes in the form of "Case Studies". The following is an encapsulated version of one such success:

Case Study I

Situation: A family was caught in an uncomfortable quagmire between our group client's fully insured coordination of benefits provisions and a spouse's self-funded health and welfare plan's frozen benefit payments. This 30 month old problem was simultaneously presenting the innocent family with threatening letters from creditors and doctor's offices who would not schedule needed medical and dental visits until over $5,600 of back payments were received.

Results: Once our Customer Service experts were made aware of the situation we immediately became the family's advocate. We had to make multiple phone calls, craft special e-mails and make personal visits to the appropriate union, insurance carrier and physician offices for quick resolution. The family's good credit history was preserved. Tough deadlines were met

and complicated benefit recalculations were offered (with clear concise written explanations) to get benefits payments reversed and confirmed. Trust was restored, two year old claims were recalculated and the family members were once again welcomed as "patients in good standing" with several physician offices.

This problem was solved because we have experts who:

• Understand complicated "Coordination of Benefits Provisions,"

• Can craft superior written communications, and

• Are patiently, pleasantly, persistent and professional in negotiation techniques until our client is satisfied.

Case Study II

Situation: A young child suffered an unfortunate accident when a finger was severed. The child was immediately taken to the emergency room of the nearest rural hospital. The rural hospital had to refer the family on to the nearest large hospital. However, since the child had been given morphine the parents were given the choice between an ambulance and their own car. The family chose the ambulance with para-medics, because of the possible side effects of the powerful drug on a small child. The health plan denied the ambulance and we were asked to intervene.

Results: The child's thumb was successfully reattached, but the insurance carrier denied the ambulance claim. Summit was called in to help and we went to work in a professional, persistent manner. We used the contract and the emergency room report and additional information from physicians via appeals mechanisms until the proper answer was given and the ambulance claim was paid in full.

Case Study III

Situation: Summit received a call from a group insurance client with a tough billing problem. They had finally discovered that they had mistakenly left an employee on their medical coverage for over six months. The employee had provided proof that they now had coverage with the spouses' employer, but the carrier's contract stated they would not go back more than 60 days to retroactively term the employee.

Results: We used our relationship with the carrier, along with the proof of other coverage, to get the entire six months of premiums refunded. We are not promising to be able to cause a carrier to consistently go above and beyond their contractual billing and eligibility obligations, but we always work to get the client's desired outcome and we are frequently successful!

Case Study IV

Situation: In today's market place there are many opportunities for sensitive out of network claim situations where Summit Financial Group is brought in to "fix" the situation to satisfy the provider, employer, employee and a dependent.

An employee of one of our group insurance clients was diagnosed with an unusual cancer. The cancer was diagnosed by an in network primary care doctor. The primary care doctor referred the member to an in network specialist. The specialist then referred the patient to an out of network doctor who specialized in treating this unusual cancer. We then worked with all parties to coordinate a surgery in an out of network facility with out of network surgery team.

Results: We worked with carrier, the physician's network, doctor's offices and several hospitals to solve this situation. After a great deal of negotiating in a short time frame we were able to arrange for the most qualified (only doctor who could perform this procedure) out of network specialist to perform the surgery. Everyone was happy and the entire claim was paid as in network.