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Medical Management
Medical Cost Savings and Containment
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
Historical Claims Auditing by Covered Person
Additional Comprehensive Medical Claims Savings
Services
Disease Management and Additional Cost Containment
Protocols
Wellness Programs
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.
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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 recently implemented a new 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.
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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. Last year, PHP identified
front-end savings of 1.5 to 2.5% on non-liability claims preventing the need
for recover efforts and associated expenses.
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.
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Out-of-Network Fee Negotiation Services
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Diagnosis Related Group (DRG) Audit Services
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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.
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Disease Management and
Additional Cost Containment Protocols
Meaningful and fair monitoring and controlling of healthcare costs.
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.
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Prior Authorization
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Pre-Certification
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Utilization Review
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Maternity Program
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Chronic Disease Management
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Case Management (Concurrent Case Review and Discharge Planning)
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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. For first time expectant mothers, PHP sends a
complimentary copy of "A Miracle in the Making" in effort to ensure mother and
baby are as healthy as possible.
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Wellness Programs
PHP promotes employee health. Finding potential health problems before they
require costly treatment and offering a variety of opportunities to help your
employees adopt a healthier lifestyle are just a few of the ways we help to
decrease healthcare costs.
In conjunction with any well care benefits an employer may select, PHP sends out
various educational and informational pieces and also works with employers who
wish to institute employee health education programs and various wellness
initiatives.
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MyNurse 24/7 Nurseline
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MyHealth 24/7 Online Tool
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Smoking Cessation Incentive Reimbursement
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Quarterly PHP Newsletter
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Healthy Moms and Babies Services
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Weight Loss Incentive Reimbursement
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Discount Health Club Memberships
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Cholesterol and Diabetes Management Self-help Materials
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Health & Wellness Mailing Stuffers
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Voluntary Wellness Related Programs
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Discount Community Health Classes
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