Regional Care is very focused on ensuring that our clients contract with the most effective PPO available for their covered participants. This isn’t as simple as it appears. Our experience has shown us that there are vast 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:
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”.
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.
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.
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.
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.