Claim Repricing and Discounting
Workers' Compensation patients' medical bills in 46 states are paid based on fee schedules published by each of the states, not on the billed amount on the claim from the provider. Some providers will accept an amount below the fee schedule as payment in full. Medical bills for Workers' Comp patients in the 4 Non-Fee Schedule states are paid based on the billed charges or on discounts secured below those charges. HHC Group reprices Workers' Comp claims to fee schedule and secures discounts below fee schedule on many claims. We also secure discounts from the billed charges in non-fee schedule states. HHC Group guarantees that we will reprice all Workers' Comp claims to fee schedule, secure any discounts and return the claims for payment within 5 working days, unlike some companies that can take weeks complete the process.
Fee Schedule States
Repricing Claims to Fee Schedule
To ensure accurate repricing of medical bills for Workers' Comp patients in fee schedules states we have created our own Workers' Comp repricing software. We have a dedicated Workers' Comp Compliance Officer whose job it is to make sure that all updated fee schedules are loaded to our database and fully tested to ensure repricing accuracy before the updates go into effect.
Claims Negotiation – Discounting Through PPO Networks
Some providers in fee schedule states will accept payments less that the fee schedule amount for the services they provide. We secure these discounts with providers in two ways: first, through Claims Negotiation; and second by accessing agreements the providers have with preferred provider organizations.
After the claims have been repriced to the FS, those of sufficient size are sent to our team of attorney negotiators. This team works directly with the provider to get them to agree to accept an appropriate amount below the fee schedule for their services. Importantly, the providers supply signed confirmation that the negotiated amount is accepted as payment in full for their services.
Additionally, HHC has established relationships with major national, regional, and local preferred provider organization networks (PPOs). These networks have pre-negotiated rates below the fee schedule that participating providers will accept as payment for their services. For larger claims with discounts we double check with the network to confirm that the provider is currently contracted with them and that the discount taken is correct, minimizing the potential for any reversals.
The HHC Group Guarantee
We guarantee to reprice, secure the discounts below FS and return the claims for payment within 5 working days.
Non-Fee Schedule States
Workers' Comp patients' medical bills for the same services can vary by tens of thousands of dollars from one provider to the next. In addition, many provider bills include mistakes, erroneous disease codes, or unbundling that artificially inflate the amount due. That's why we offer our clients a wide range of services designed to significantly reduce their Workers' Comp healthcare spend.
Upon receipt of your Workers' Comp medical claims in non-fee schedule states, our team of skilled attorney negotiators goes to work to resolve the case using our proven approach. Our team works directly with the providers – from hospitals, to doctors' offices, to imaging centers. If the provider issues a bill, our team will work with them.
Using a proprietary database of pricing information – gathered over more than twenty five years of negotiations with the provider or similar providers in the same market - published databases and their many years of negotiating experience, our skilled negotiators work collaboratively with the provider to achieve a mutually acceptable resolution, one that results in our clients paying only an appropriate for the services their employees/members receive.
Importantly, the providers supply signed confirmation that the negotiated amount is acceptable as payment in full eliminating any balance billing or lost discounts.
HHC has established relationships with major national, regional, and local preferred provider networks (PPOs). When our clients submit the Workers' Comp claims, we can often reprice the claims to significantly lower, pre-negotiated rates to which providers in these networks have already agreed. For larger claims we double check with the network to confirm that the provider is currently contracted with them and that the discount taken is correct minimizing the potential for any reversals.
The HHC Group Guarantee
We guarantee to turn around Claims Negotiation and Repricing service claims in five days or less – always with a sign-off from the provider, so the price we negotiate stays firm.
Every Breed of Specialist for Every Type of Review
For claims that require an independent determination of medical necessity, causation, medical appropriateness, general acceptance, or ability to return to work, HHC offers independent Utilization Reviews. And with a network of medical professionals in almost every medical specialty, we're ready for virtually any type of review that comes our way.
By Qualified Medical Professionals
We have assembled a team of highly-qualified, credentialed professionals including board-certified physicians, physical therapists, psychologists and other professionals, individually vetted using stringent guidelines to ensure their fitness for rendering decisions. As a result, our team includes among the most respected medical professionals in their respective fields.
Sometimes reviews need to be expedited due to a patient's treatment plan – such as when surgery is required or a high-cost drug is prescribed. For these types of urgent peer reviews, our reviewers are available 24/7, and we can provide reviews with same day, one-day, two-day, or three-day turnaround.
Objective, Impartial, Unbiased
We provide utilization reviews in a variety of circumstances and for different types of clients. In all cases, we ensure an objective analysis of the patient's medical circumstances, such as:
About Our Process
- When a patient/plan member appeals the decision of his or her insurance company to access care or medication
- When a payer wants to ensure the most appropriate and cost effective approach for a complex medical condition
- When a payer, such as a workers' compensation plan, wants to determine responsibility for coverage or when a patient can return to work
Our Medical Director and Unitization Review Nurse Supervisor (RN) oversee Utilization Reviews, and they apply a stringent quality assurance process. They ensure every report answers pertinent questions, that appropriate medical guidelines are referenced, and that the contents of the report are easily understandable – not only by trained medical professionals, but by a layperson.
Independent Medical Examinations
HHC Group offers high quality Independent Medical Examinations (IMEs) for cases requiring an examination by a doctor or other licensed healthcare profession to help answer specific legal or administrative questions related to workers compensation or disability claims.
Performed By Qualified Medical Professionals
HHC utilizes only Board Certified specialists who are experienced IME examiners. All have been in practice for at least 5 years and have been thoroughly vetted to ensure they will provide high quality, unbiased reports.
Our Proven Process
We've design the process to make it as easy for our clients and their employees. You just fill out the 1 page HHC IME Authorization form, provide the medical records and questions to be answered and approve the charges prior to the exam. We confirm each appointment with the patient, client and physician by phone, letter and email, and provide translators, transportation and even overnight accommodations should the need arise. We even call the patient 48 hours prior to the exam and then check on the day of the exam to make sure they arrived. Of course, our Utilization Nurse Supervisor and Medical Director review each report to ensure that all questions have been fully answered.
Functional Capacity Evaluations and Vocational Evaluations
HHC Group also offers administration for Functional Capacity Evaluations (FCEs) and Vocational Evaluations (VEs) used by physicians, case managers, and employers to transition injured workers from disability to function and employment. An FCE is a series of tests measuring physical strength, range of motion, stamina, and tolerance to functional activities, including lifting and carrying. FCEs and VEs together can be used to evaluate work tolerance, the necessity for work restrictions and earning capacity.
Our Proven Process
As with URs and IMEs, we use only qualified, vetted physicians and other professionals to conduct the evaluations. Again, all a client has to do to order a FCE is fill out the Authorization form and approve the payment amount. We follow the same scheduling and notification process as for IMEs to ensure the evaluation takes place and the report is forwarded to the client on a timely basis.
Other Cost Containing Services
In addition to its Workers' Comp related products, HHC Group offers a full continuum of services to reduce the cost of your claims, including Medical Bill Review, Referenced-Based Pricing, and more. Click here
to learn more.