Cost Savings Initiatives
Our goal is to deliver the best quality care at the lowest possible cost using proven and medically accepted cost-containment techniques. By using an integrated structure of automated programs and key partner relationships, coupled with our high standard of processing accuracy, PHP has established an approach that continuously supports quality of care and services while locating opportunities for improvement and significant cost savings that are passed on to you.
Service Provider Code Auditing
Inappropriately or inaccurately coded physician claims are a waste of your financial resources and, when undetected, can cost thousands of dollars. PHP uses an automated code editing system that allows us to detect, deny, and reprice inappropriate, inaccurate physician claims before they are paid. Our system's clinical and coding claims software compares medical procedures with industry standards, flags deviations, and suggests more appropriate coding options. It is able to define relationships with procedure codes on physicians’ services across all medical specialties. The result is a comprehensive and accurate code editing system that produces valid claims payment--saving you money.
Historical Claims Auditing by Covered Person
While our service provider code auditing software works to identify individual problem claims, PHP's integrated cost management system continues to work for you by adding more indepth services as another layer of savings protection. We have implemented a program that conservatively projects additional savings. This software works to track and analyze claims by taking historical claims data - not just current claims data - into consideration when applying overpayment detection: duplication, unbundling of services, problem coding, new patient inappropriateness, and many other cost-detection features. This program examines the "big picture" of your claims data as a whole and discovers patterns in the relationships between disparate data and generates ad-hoc reports as needed to correct issues.
Additional Comprehensive Medical Claims Savings Services
Identifying and determining the best possible methods of reducing the cost of a claim in any given situation takes a wide range of specialized resources and experience. PHP has what is needed to get the results you desire.
Coordination-of-Benefits. By transferring your claims risk to responsible first party coverages; such as, a primary health carrier coverage, the medical payment coverage under auto, homeowners, or premises insurance policies, PHP delivers front-end savings to you. We know that you have better uses for your money than to loan it to an alternate health plan or casualty insurer and we work to make sure that doesn’t happen.
Claims Cost Containment Services. Pre-payment and post-payment programs designed to address any out-of-area or non-network medical claims. From cost to charge ratio analysis and discount negotiation services through hospital bill audits, DRG validation, and contract compliance issues, our goal is to reduce your healthcare costs.
- Out-of-Network Fee Negotiation Services
- Diagnosis Related Group (DRG) Audit Services
- Hospital Bill Audit Services
Subrogation and Reimbursement Recovery. In the event that alternate liability is established after a claim has been paid, we will work on your behalf to gain reimbursement from the party or individual ultimately responsible for the charges.
Disease Management and Additional Cost Containment Protocols
Through a series of services and evaluations that take place before, during, and after medical treatment, PHP is able to control medical costs while ensuring that the level of care is consistent with an individual's medical needs. We have established a variety of diagnoses, which trigger automatic outcome reviews of a patient's hospital and physician medical records. Our program utilizes nationally recognized guidelines to ensure that they meet industry accepted standards.
- Prior Authorization
- Maternity Program
- Pre-Certification
- Chronic Disease Management
- Utilization Review
- Case Management (Concurrent Case Review and Discharge Planning)
Case Management. Concurrent Case Review and Discharge Planning is employed in potentially cost-intensive, catastrophic cases. Industry data shows that catastrophic cases can account for as high as 20% of a company's healthcare expenses. That means the amount of money saved through case management can be substantial. By anticipating the length of stay, the possible need for rehabilitation, or home healthcare and other significant treatment plans, we can plan for care that minimizes cost without sacrificing quality.
Utilization Review. To control medical costs while ensuring that the level of care is consistent with an individual's medical needs, a series of services and utilization evaluations take place before, during, and after medical treatment.
Chronic Disease Management. Ongoing awareness and care management of chronic diseases such as diabetes, high blood pressure, and high cholesterol reduces health risks and overall healthcare costs. Information is disseminated regarding health promotion and disease management programs through individual mailings to the specific "at-risk" population as identified through health risk appraisals, pharmacy data, medical claims data, or the employee's self-notification.
Maternity Program. PHP has a highly specialized obstetrical and neonatal case management program to help with the care, coordination, attention, and education your employee may need. Continued management is offered by PHP on perinatal and neonatal cases.