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differences in the quality of Preferred
Provider
Organizations (PPOs) available for contracting in any market.
For
that reason we have dedicated a team of PPO Analysts to continual
research of PPO quality and cost effectiveness and maintain a database
of PPOs covering over 125 geographic areas in the United States.
On an ongoing basis we utilize a
comprehensive
data gathering tool to gain current information related to PPOs, their
contracts and their real savings. This tool captures five key
components used to rank PPOs in each geographic area:
Provider Management:
Gains an
understanding of the support provided to the Claims Payer in handling
problematic providers, related to inappropriate billing, including
unbundling, upcoding, undocumented charges and unreasonable
“mark-ups”.
Geographic Access:
Reviews the
volume and location of different providers used most frequently by
covered participants and those which if not contracted could result in
extensive out-of-network cost for the Plan Sponsor.
Provider Disruption:
Reviews
the PPO contracting strategy related to lesser discounts for a broader
network versus deeper discounts for a more limited network.
If
the limited network strategy is used we review our negotiation success
on the excluded providers to determine if the overall cost structure
for the geographic area is beneficial.
Contract Quality:
Reviews the
contract structure of the most utilized and highest potential cost
providers to determine if the arrangement places the provider at risk
to deliver services cost effectively. Examples are DRGs, case
rates and per diem arrangements on hospitals and fee schedules with
controlled “carve-out” charges like injected drugs.
Contracts without provider risk require much greater scrutiny of claims
being negotiated and re-priced.
Actual Contract Savings:
Reviews the PPO’s reported savings between billed charges and
amounts allowed by the contract. Significant effort is placed
on
gaining accurate reporting of savings minus disallowed charges and
coding adjustments.
Regional Care maintains complete
independence in
its relationships with PPOs and our revenue is not impacted by use of
one PPO versus another. We ultimately choose the PPO that
most
benefits our clients and the Plan Sponsor.
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