Blue Cross/Blue Shield
Health Decisions, Inc. appreciates the unique role and leadership position Blue Cross/Blue Shield plays in the healthcare community. We have experienced a very positive relationship with BC/BS companies, both directly and through clients.
Health Decisions also has an extensive familiarity working at the technical level of BC/BS companies where we have solid experience working with the NASCO, ITS, FEP and other systems.
Health Decisions offers the most comprehensive Post Payment Administration system in the industry. Our BC/BS clients already have claim recovery efforts in place and we do not disrupt these existing relationships. We pursue only those claims not already identified by existing recovery efforts, which typically return 1-3 percent.
No system, no matter how good, can compensate for the pressures for quick claim turnaround that prevents full investigation of all claims prior to payment. Because our review does not start until after a claim is paid we have the time to look into the difficult to document details that lead to recoveries.
Health Decisions goes much deeper seeking claims to recover by conducting a review of 100 percent of claims in more than 25 areas to identify and recover claims paid that are not the payor’s responsibility.
Health Decision’s approach to claims recovery works so well because we:
- Combine existing data files from various sources to identify cases that fit recovery profiles in over a dozen areas from COB and subrogation to Medicare recoveries, divorce decree enforcement, and provider payment verification.
- Delve into the details of each case to find facts not known when the claim was paid. Tools we use include special surveys, verification calls, and independent documentation.
- Don’t stop until a claim is collected or closed. Our collections do not involve individual enrollees. Instead, we focus on other plans, providers, Medicare and judicial judgments to get recoveries.
- Track and account for those recoveries using Health Decisions’ automated credit tracker tool that can account for all outstanding recoveries from any source.
Our BC/BS client selects the level of involvement desired. It can be as simple as providing approvals to proceed that commence each of the three steps. Because BC/BS companies have recovery efforts in place, Health Decisions will coordinate with these efforts and avoid any duplication.
Because Health Decisions is at the cutting edge of technology we can help BC/BS companies better deal with:
- The fallout of automated adjudication of claims
- fraud and abuse detection and prevention
- Medicare recovery
- identifying the best Continuous Quality Improvement (CQI) solution
- satisfying HIPAA and other regulatory requirements
Health Decisions Post Payment Administration system for payors includes emphasis on span of control, financial return, staffing, implementation, and CQI. Our suite of services covers data handling, data processing, case investigation, and case updates.