With a strong emphasis and continued commitment in Cost Containment, we have invested in a staff of 60 Utilization Management Professionals, 30 of which are nurses. Our Cost Containment is a Core Competency of HealthComp.
Cost Containment services:
Provider Fee Negotiations: With cost-management solutions being critical in today’s insurance industry, HealthComp’s Utilization Management Department has established a Provider Fee Negotiations Unit to secure discounts on provider billings.
When a member chooses or is forced outside of the Network, the facility or provider is not bound by any contract to keep costs at a reasonable rate. Special Contract Pricing Negotiations are attempted on Non-Network claims processed at HealthComp. The amounts negotiated are standardized at $1000 for Professional and Facility fees, but any claims may be referred to the Unit for negotiations.
Our trained negotiators attempt to get a discount off the claim incurred, on behalf of our Clients and to prevent the members from being balance billed after usual and customary pricing is applied. The Special Contracts Pricing Negotiations Unit will also attempt to establish direct contracts with Non-Network providers based on agreed upon criteria. If this cannot be done, then Single Patient Agreements are negotiated.
In-Network Steerage: During Precertification Process Utilization Management, works to identify in-Network providers in a desirable geographic location during that may otherwise be unknown to employees. Out-of-network benefits vs. In-network benefits are explained from a coverage, deductible, copay and coinsurance perspective. In-network discounts benefit the Health Plan and the participant.
Review Medical Necessity: To assure requested services meet the national guideline of medical necessity. Independent medical review organization is used to assist and provide objective determination on Medical Necessity.
Medical Claims Review: Medical claims review is the process used to assure that provider billings are accurate, reasonable and appropriate for services that have actually been provided.
- Significant cost savings to the Plan
- Early identification of potential Case Management patients
- Increased ability to trend possible questionable billing practices
- Increased accuracy in claims processing
- Timely notification to Reinsurance of High dollar cases