By Linda Chase, BA, RNC, CCM and Medical Risk Consultant for Symetra Life Insurance Co.
After a visit to the local urgent care one Saturday afternoon for bruising and a relentless cough, Mike, a 23 year-old father of two whose name has been changed for privacy, received a devastating blow. Routine blood work revealed that Mike had leukemia, a cancer of the blood and bone marrow. Unfortunately, after further testing, it was learned that Mike had a particularly aggressive form of leukemia and the only hope for cure was to undergo a bone marrow transplant.
After receiving an urgent call for transplant benefits from Mike’s physician, the claims office of Mike’s medical plan immediately notified Symetra Life Insurance Company (Symetra), the plan’s stop loss provider, of the potential large claim.
Upon receiving the call, a Symetra medical risk consultant (MRC) obtained the necessary demographics and connected the patient with one of Symetra’s Transplant Centers of Excellence networks.
A Center of Excellence, or COE, is a transplant facility that has vast experience in the field of transplantation and performs several transplants a year with proven quality outcomes. Symetra has contracted with three different COE networks to provide quality, choice and strong discounts to our valued clients and to help minimize the risk and costs associated with transplantation.
On August 3, 2007, Mike successfully received his bone marrow transplant. After a 24-day hospitalization, the hospital bill totaled $515,000. However, having accessed one of Symetra’s transplant network COEs, the claims were re-priced to $249,000, a total savings of $266,000 or 52 percent.
Transplants more effective, more expensive
With continued advancements in medical technology, transplant procedures and success rates continue to improve. Physicians are now able to effectively treat more complex medical conditions with transplantations than ever before. However, these improvements do not come without a price. Transplants remain one of the most complex and costly of all medical procedures, representing significant risks to payers.
Studies have proven the best way to contain transplant costs is to choose a Center of Excellence (COE). In 2007, Symetra assisted clients with accessing and placement of 94 patients within these contracted networks, reducing transplant claim expenses by $4.7 million, with an average discount of 42 percent.
Using a network transplant COE minimizes costs by providing access to substantial discounts and by reducing transplant complications, re-transplantation rates and lengths of stays. Symetra’s access to three different COE programs ensures that there is a quality center in almost every geographical area within the United States.
To access Symetra’s transplant COE program, please contact your designated Symetra excess loss claims office  or your assigned medical risk consultant.
Linda Chase, BA, RNC, CCM, is a medical risk consultant (MRC) for Symetra Financial. She has more than 26 years combined experience in the medical field and health insurance industry and holds degrees in Nursing and Business Administration. As an MRC at Symetra, Linda oversees the management of ongoing catastrophic medical circumstances, and works with underwriters in the risk assessment process for new and renewal business. She acts as a liaison between TPAs and our partner vendors’ managed-care programs.
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