Sophisticated tools to eliminate the disparity in payer-provider interactions
The NSA requires affected providers to dispute any out-of-network insurance payments through a byzantine process while navigating conflicting guidance from various entities. We provide a turn-key solution that transparently retrieves the money you are owed while minimizing manual input from your team
A move away from fee-for-service can create enormous opportunities for health systems, but also requires attention to detail: a single non-adhering physician, or overbooked imaging center, can cause havoc. Additionally, payers can often destroy gainshare through bad-faith interpretations of a contract. We track your performance in real-time, provide outputs to all stakeholders including physicians, and link that performance to overall gainshare to avoid nasty surprises.
The largest insurers have developed sophisticated national infrastructure to drive down costs as much as possible - for example, United pays out $250B annually which is roughly 1,000 times the total income of the average hospital. We provide legal and technical sophistication to benchmark your rates against multiple sources including price transparency, quantify how obtuse contract lines will actually affect your revenues, and redline any qualitative contract language that could be used against you.
Insurers who can’t win discounts through aggressive negotiation often resort to increasingly sophisticated revenue cycle tricks, such as denials or underpayments hidden in obtuse 835 adjustment reasons and justified through benign-looking contract language. We monitor your billing and remittances to immediately catch these changes, allowing immediate pushback before months of losses have accrued. And if it comes down to it – we have a close working relationship with a top tier provider-focused law firm that frequently wins cases against the biggest insurers in the country.
Our track record speaks for itself
Earned for our clients across our products
Increased revenue through proactive monitoring of your reimbursement
Initiators of Federal No Surprises Act disputes
Savings using our no surprises act tool vs. internally developed processes
Increase in FFS managed care rates with our price negotiation solution
Matching and overcoming the capabilities of a payer’s multi-billion-dollar contracting department requires some techniques
Our company consists of provider and payer-side healthcare market leaders, top-tier provider side managed care litigators, clinicians, and cutting edge developers. Combining those vastly different viewpoints into a coherent solution is what makes us special.
Everybody is now using the same servers - United/Optum uses AWS. The key differentiator is the software, and we live in a time when either misunderstanding a business need, or a mistaken hyper-detailed technical decision (Python 2.7 or 3.2!) can spiral into to a weeks-long headache for a CEO. While large insurers have multiple layers of bureaucracy, we make our choices unencumbered by decades of legacy systems or demands of tangentially related VPs.
Switching to a new system doesn’t have to be hard. We connect our core software to your existing processes quickly and simply through temporary streamlined work flows; then build out a mature integration to your systems in a way that saves us all time and effort. Our goal is to minimize the full cost of your solution, which includes your time, resources, and focus
The No Surprises Act, while well intentioned, severely limits the ability of affected providers to dispute out-of-network insurance payments. To do so requires navigating a byzantine path with contradictory guidance from various federal and state entities
Payers, aware of the difficulty this poses to providers, have taken the initiative to massively reduce out-of-network payments to levels at or below Medicare.
We can help you retrieve the money you are owed. We have have a close working relationship with a leading US healthcare law firm, to develop software that streamlines this process for you - all we need is your claims data, payer remittances, and participation in some guided discussions to get you started. Before long, insurers will be reaching out to sign contracts.
Our legal, US health care, and revenue cycle experts can address the day-to-day issues, letting you provide as much or as little input as you like
A top US healthcare law firm addresses legal issues and writes compelling arguments for arbitration
We determine offer rates using all relevant data sources including price transparency, FAIR Health, client contracts/SCAs, and previous win/loss records
Our comprehensive user interface provides detailed views into everything we do, allowing you to review performance, communicate successes, or focus efforts
A move away from fee-for-service can create enormous opportunities for health systems, but creates many possible points of failure: some misaligned incentives, a non-adhering physician, or an overbooked imaging center can cause havoc. Additionally, payers can often destroy gainshare through bad-faith interpretations of a contract.
Addressing these issues before they grow requires a lot of hard work and timely interventions. Those interventions require fresh and detailed data, and rapid turnaround of analytics on that data
Identify gaps in care leading to patient complications or avoidable spend
Track performance of all gainshare participants to determine positive or negative trends
Develop new interventions or map existing interventions to patient populations and communicate to stakeholders their financial impact of performing those interventions
Regularly update gainshare performance for the system as a whole against payer-calculated metrics
By staying on top of your performance and transparently tracking successes of all stakeholders, we keep the details straight, participants aligned, and avoid any nasty surprises.
The largest insurers have developed incredibly sophisticated national infrastructure to drive down costs as much as possible - for example, United pays out $250B annually in “medical loss” which is roughly 1,000 times the total income of the average hospital - so they can spend enormous sums developing methods to outsmart hospitals and reduce those payouts.
These insurers know how much hospitals earn from other insurers; how much revenue is being clawed back from providers through denials and underpayments; and stay abreast of opportunities to shift volume to lower-cost providers through narrow networks, patient education, or redirection.
Price transparency data quantifies your competitors' negotiated rates with each insurer
Sophisticated modeling tools accurately determine expected reimbursement from the most inscrutable contracts
Legal review of contract language identifies and avoids negative contract language
Targeted increases into into growing service lines drives revenue gains beyond payer-calculated amounts
By considering all aspects of a contract in tandem, we can get you a deal that will lead to increased realized revenues, and not just a higher rate on a piece of paper that is clawed back through denials.
As the cost of health care rises and Medicare/Medicaid rates remain flat, the negotiations between payers and providers have gotten increasingly hostile. Where insurers can’t win discounts through aggressive negotiation they often resort through increasingly sophisticated revenue cycle tricks, such as denials or underpayments hidden in obtuse 835 adjustment reasons and justified through benign-looking contract language.
We monitor your billing and remittances to immediately catch these changes, allowing immediate pushback before months of losses have accrued. And if it comes down to it – we have a close working relationship with a top tier provider-focused law firm that frequently wins cases against the biggest insurers in the country.
