Claims Optimization Program

We understand the need to control health care costs and reduce claims experience for employers. The lower an employer's costs, the stronger their overall financial position – and the less cost shifting to employees. Whether it's the employer's dollar or our dollar, we manage it just as aggressively. Depending on your funding option, your claims optimization program could include:

Provider Discount Program – A national wrap around or supplemental provider network that applies discounts when possible to out-of-network hospital, physician, ancillary and other health care provider claims.

Professional Negotiation Services – Negotiates discounts when possible with out-of-network providers.

Facility Charge Allowance – Determines the reasonable allowance based on services provided by inpatient and outpatient out-of-network facilities.

Hospital Bill Audit – Provides on-site audit service for providers with total charges of $10,000 or more.

Hospital Credit Balance Audits – Provides on-site audit of credit balance accounts at provider facilities and negotiates to recover overpayment.

Subrogation Services – Reviews paid claims and requests additional information if a claim is the result of the actions of a third party and, if so, pursues settlement.

Special Investigative Services – Identify, monitor and report suspected fraudulent, abusive and/or questionable business practices.

Fully Automated Online Edits and Utilization Mechanism – Achieves savings through clinical editing.

Employer Resources

• Access Your Account
• Group Plan Member Services
• Find a Group Sales Office

 

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