Health Systems International

Our Services: Repricing

REPRICING: What is it?

Repricing is the recalculation of billed medical charges based on the rates and rules a PPO has negotiated through its provider agreements. HSI manages the complexities of administration and data maintenance with over 120 connected networks and connected payors throughout the world.

REPRICING FOR PAYERS:

HSI partners with claims payors to relieve the administrative burden inherent with repricing management through the following services:

Primary Network Services

HSI provides "single source access" to over 100 of the USA's leading primary PPO networks. The primary network typically requires the client to utilize network logo identification on an ID card and/or steerage to providers through the use of benefit differentials. Providers associated with a plan's primary network are typically considered "in-network."

Secondary / Speciality Network Services

HSI provides secondary network access for out-of-network medical services. In addition, HSI provides a selection of supplemental or specialty networks designed to provide savings for specific services such as lab, dental, DME and more. Customers can maximize their savings by utilizing HSI's network connections and sophisticated rules engine to design and administer a hierarchy of networks that will provide the largest impact on their claim flow.

Claim Negotiation

For charges that are not repriced through a network, HSI offers services to negotiate a discounted price on a payor's behalf after the service has been rendered. HSI's claims negotiation service is strategically designed to discount claims that fall out-of-network, providing clients a complete solution to their cost containment needs. HSI works with both the payor and providers to establish fair reimbursement for out-of-network claims. By investing in expertise, data, and positive provider relationships, the Company is able to earn discounts on 97 - 99% of healthcare claim dollars in total.

REPRICING FOR PPOs:

HSI's network solutions are ideal for PPO networks that do not have internal repricing operations or are moving towards outsourcing.

HSI is able to load a PPO's demographic fee schedule data and become the back office for repricing services to all customers of the network.

Technology and Data Management Services

HSI provides fully outsourced technology and data management services to PPO networks. The Company's technology and data management services are supported by its claims repricing technology. HSI's data management services include automated loading and maintenance of provider demographics and fee schedules, electronic claim receipt, programming of client and network rules, and online access to claims and reporting.

Network Repricing and Distribution Services

HSI also provides PPO clients with outsourced repricing and distribution services for their network. HSI has secured distribution and administration rights with its partner networks. This permits HSI to distribute network access and reprice claims for existing or prospective clients. Under full outsourcing arrangements, HSI will act as the exclusive administrator for several networks.

COMPLEXITY OF REPRICING: What are the issues?

On average, payors will access upwards of 20 different PPOs to serve the diverse health benefit needs of its population. This requires multiple connectivity solutions, claim feeds, formats, processes, and workflows for each contracted network, which is complex and difficult for payors to manage internally – HSI's Single Source Payor Repricing Solution solves these issues!

Industry Challenges:

• The typical TPA uses over 20 PPO networks
• Turnaround / time delays
• Multiple workflows / PPO connectivity / data formats / manual re-entry
• IT staff time consumed loading provider files
• Little to no savings outside of primary network
• Multiple providers, provider locations, tax IDs, provider specialties, confidential date-sensitive provider fee schedules, and network access rules
• Inability to load or obtain PPO proprietary fee schedules