NHSI NETWORK & COST CONTAINMENT SOLUTION

The NHSI Cost Containment Solution is the single source solution for Insurance Carriers, Re-Insurance Carriers, TPAs, Unions, Self-Administered Employers and Travel Assistance Companies. NHSI utilizes technology and experience to maximize global savings to an ever-shrinking health benefit dollar. Payer organizations have historically utilized several companies to perform these services that help contain claim costs. The results are an uneven approach that yields little saving at great cost. Payers also expend costs to interact and track the results from these companies.

NHSI has bundled these services into a single service that assures our customers that every claim is reviewed for maximum savings. Our approach is unique and via the NHSI web site our customers can track results and reports on a real-time basis and communicate these results to their customer base.

PPO Primary Network

NHSI provides access to the best primary networks available comprised of over 500,000 providers located in all 50 states. NHSI, utilizing a state of the art review, will precisely match each customer to the right network configuration. NHSI will provide a claims disruption analysis and a demographic review to determine optimal network recommendations. NHSI will provide access rates of over 90% and discounts of approximately 40% when our approach to network configuration is utilized.

Secondary PPO Network

The NHSI secondary network PPO assures that all claims without a primary network match are reviewed for a PPO discount. NHSI reviews claims electronically or on a paper basis if necessary to assure a discount. Our secondary network provides access to 400,000 providers nationally. NHSI is successful over 80% of the time when providing a discount to a non-primary network claim. Our discount rate is approximately 28%.

Centers of Excellence Transplant Network

NHSI, through strategic partnerships, provides access to a nationally renowned network of facilities and providers for transplants and high-risk disease treatments. These facilities provide evaluation and screening, transportation, global pricing and post transplant care to all patients. Strict credentialing criteria and stress success rates among the member facilities are employed. The primary goal of this program is to match the patient procedure to the right facility.

Fee Negotiation

NHSI will review all claims where both a primary and secondary PPO network fails to provide a substantial discount. NHSI will also review any claim over $5,000 that does not have at least a 15% discount utilizing our other cost containment programs. NHSI will directly negotiate with provider senior management in order to secure the right discount. All negotiations are in writing. Our goal is to meet a savings minimum of 20% for each claim negotiated. NHSI has been successful 90% of the time with a savings rate of 24%.

Provider Overpayment Recovery Program

NHSI will assist in the recovery of overpayments to providers. NHSI will review all claims for duplicate payments, COB and subrogation potential. NHSI combines system review with hands on analysis to determine if overpayments have occurred. NHSI will assist in the recovery of any overpayments. Full reporting capabilities are available online for review.

Claims Unbundling Program

NHSI will review all claims files to determine if claims bundling /unbundling or up coding has occurred. Claim bundling and up coding are common provider billing practices and left unchecked can add over 5% to every claim dollar. Our software will apply over 150 edits to review virtually every common bundling and up coding practice. If necessary NHSI will request records and audit a claim to finalize a determination. NHSI will generate reports for all claims reviewed and adjusted to reflect an up coding issue.

Claims Audit Program

NHSI will directly audit large dollar or unusual medical claims. Medical records are reviewed and matched against billing records to eliminate duplicate charges, services not rendered or fraudulent billings. Over 10% of all claims payments result from inaccurate provider billings. NHSI provides a complete claim analysis of our findings and will assist in the recovery of any overpayment.