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Out-of-Network Cost Containment

Overpayment Detection



Advanced Services

HeC aggressively works to contain costs with its Advanced cost containment services that include medical cost management and overpayment detection and prevention. These facilitated services do more than just reduce administrative costs through efficiency gains; they directly impact the bottom line by virtually eliminating overpayments and containing your out-of-network exposure. 

Medical Cost Management

Medical cost management services include claim evaluation and negotiation, supplemental network coverage and hospital usual and customary recommendation programs for out-of-network, out-of-area and non-network charges.

Out-of-Network Cost Containment

HeC uses state-of-the-art technology and highly trained claim analysts, to ensure that your out-of-network charges are reasonable. Claims meeting a mutually agreed upon threshold are analyzed for upcoding, unbundling, overcharges or suspected fraudulent activity. Medical billing and coding professionals further evaluate each claim and contact the provider directly to discuss any billing, coding or pricing issues that have been detected. A signed agreement is secured on each negotiated discount to ensure no balance billing to the insured or payor. This service can be done on a prospective, concurrent or retrospective basis.

Hospital Detail Analysis

The Hospital Detail Analysis (HAD) services provide an extensive analysis of both inpatient and outpatient hospital bills, resulting in a sound recommendation for services performed. The HAD formulas use Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC) as foundation components for calculating appropriate reimbursements, and then apply another formula to account for consumption of resources, severity of the claim and geographic pricing factors.

Supplemental Networks

HeC has indirect affiliations with national networks that can be accessed as a supplemental network to your primary networks. These networks are specifically designed to allow access to the providers on a non-directed basis.

Overpayment Detection

HeC’s overpayment detection and prevention service helps medical bill payors achieve substantial cost savings using its prior-to-payment medical claims evaluation services. Unlike other overpayment prevention solutions, this is an end-to-end package encompassing every critical aspect of overpayment detection: Duplication, Unbundling, New Patient, Inappropriateness, and many others, all united in one solution.

Historical Data Analysis

A large volume of historical data is examined – not just a snapshot of current data. Since many of the rules are based on comparison of history, this mapping is essential to ensure a comprehensive review.

Duplicate Payment Detection

Duplicate payment detection uses our proprietary near-duplicate matching algorithms to identify duplicate claims that were previously undetected.

Coding, Bundling, and Diagnosis Review

Using a knowledge base of clinical rules, HeC’s overpayment prevention solution finds claims that should be bundled under a single, less expensive code, and detects clinically inappropriate diagnoses, incomplete entries, and irregularities in coding.  A physician Variance Reporting A physician variance reporting tool is provided to illustrate paid claims, cost by provider and a summary of the reasons why the physician codes differently than his or her peers. It also illustrates the potential overpayments that have been missed and provides the defense to the rules so savings can be maximized confidently.


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