Referenced-Based Reimbursement

It’s no mystery; there are huge variations for the identical health care services. Though prices vary, higher rates do not necessarily correspond to superior quality of care. Through Referenced-Based Pricing (RBP), all facilities will be paid the same for each specific procedure.  That means that patients can search for the best facility to treat their condition, without regard to cost.  With RBP, reimbursement is set at a rate that is considered a fair market value for the services rendered.  The result is substantial savings when compared to traditional PPO network discounts.

Utilization Review/Management

You can be assured that your members will receive appropriate care when it is needed.  Our experienced medical staff is with you throughout the process.  We evaluate the appropriateness, necessity, and efficiency of the use of these health care services.  We work closely with the patients and their providers to ensure that the care received is "best in class" and that it is reasonable in cost.

Case Management

We believe that case management is a cooperative process of valuation, preparation, facilitation, and careful coordination. Our highly qualified medical staff work with patients and their families to help them understand their course of treatment.  They also help them understand their benefits, and steer them to network providers to help control costs.  Through our evaluation process, we ensure that treatment is medically necessary and meets standards of care.

Chronic Care Management

Living with a chronic condition can be overwhelming.  We understand the importance for the patients to understand their condition and their treatment.  By creating new procedures, we work hard to provide better service to people with chronic illness. We provide both transparency and coordination for those who suffer from chronic illness in order to offer better care for their needs.

Claims Editing

Accurate claims payment is our ultimate goal.  We constantly review claims for errors and omissions. Our intuitive systems have been put in place in order to ensure that all medical claims are processed correctly the first time. By verifying that all claims are correct, we provide more cost-effective claims solutions.

Dialysis Management Services

There is no question – dialysis claims are expensive. Through our research and expertise, we have developed a dialysis program that will provide significant savings to your plan, without compromising patient care.  We work very closely with the dialysis providers to negotiate fair reimbursement for their services and assist the patient throughout the process.