Negotiation Services was developed as a method of mitigating catastrophic loss, identifying excessive provider charges, billing errors and converting those circumstances to claim savings through targeted negotiation. The process has many inherent advantages to all parties connected to a self- funded medical plan. Employer groups benefit through improved claim cost and thereby reducing overall plan expenses. Carriers /Managing General Underwriters benefit through improved risk management techniques allowing more competitive underwriting producing lower rates, factors and in some cases, reduced lasers.
Product Characteristics
Negotiation Services functions differently from network discounting due to flexibility not available in a pre-negotiated provider contract. Each claim encounter contains certain caveats which must be taken into consideration when attempting to reach a provider agreement. Negotiation Services is driven by the individual composition of each claim and therefore no predetermined methodology limits a customized claim resolution.
- National in application with no blackout areas
- No restrictions on dollar amount or claim type, the service applies universally regardless of variables
- PROVIDER SIGN-OFF
- Provider sign-off eliminates balance billing and discount reversal
- Applies to in and out-of-network claims
Product Methodology
PNA methodology in the negotiation process with providers allows us to conduct the negotiation based upon detail specific to the claim in question. This unique skill set can be generally defined as a 4 step application.
Step 1 - Benchmarking Medicare allowable to billed charges by revenue code and developing a cost to billed charge ratio.
Step 2 - Engage in provider negotiations based upon audit findings.
Step 3 - Reaching provider sign-off through written agreement substantiating all aspects of the negotiation thereby eliminating balance billing and discount reversal.
Step 4 - Provider contractually agrees to the negotiated discount.
Implementation
Implementation includes decisions regarding claim flow, reports and daily administrative details, all of which are subject to discussion and can be customized to meet specific client needs. PNA can provide suggestions in the various categories best suited to address client goals. Claim outcomes recently negotiated and signed off can be presented for review to further underscore the effectiveness of PNA efforts.