You've read the news: double-digit rises in healthcare costs, again, for 2002. That means payors, large employers and providers alike will need to drill deeper for ways to control their outlays. And that means payors may want to broaden their use of repricing, or renegotiating the payments they make to providers for out-of-network care, moving them closer to in-network rates.
For large multi-state employers administering their own plans, insurance companies, third-party administrators and some HMOs, negotiating contract pricing with scores of provider organizations is tough enough. But the administrative challenge gets more burdensome with repricing. Back office staff is constantly behind on processing claims. In-boxes overflow as they wait for a claim to be repriced. Even with Internet connectivity providing help, personnel can spend real money and endless hours searching for documents, making multiple phone calls, faxing, photocopying and dispatching couriers.
Repricing tasks--especially with the tangle of differences in hospital Outpatient Prospective Payment System (PPS) rules from state to state--often become too resource intensive for payors to tackle themselves. Yet the savings potential is too favorable to ignore, especially considering that out-of-network care represents as much as 20 percent to 25 percent of all healthcare claims. Occasionally payors seek outside expertise to get the job done. In turn, sometimes the experts need help.
Such was the case for Coalition America Inc. (CAI), an Atlanta firm specializing in PPO/provider administration and healthcare cost-containment programs for TPAs, self-administered employers and managed care organizations (MCOs). "We saw a need for a benchmark standard on which to base negotiations and repricing discussions," says David Rearick, D.O., M.B.A., chief medical officer for Coalition America.
CAI looked to technology for answers--and found WinStrat[TM] software from HSS Inc. of Hamden, CT. They saw that the program not only could help them develop national cost benchmarks for hospital inpatient...