HMO profit margins have been reduced to less than 3 percent because of cost containment initiatives and intense market competition. Given this thin margin, the 2-3 percent of claims costs recovered by Health Decisions, Inc. has a dramatic effect on the bottom line of most of our HMO clients.
This increase in profitability occurs without any change in internal HMO procedures, computer equipment or software. Health Decisions accepts claims data in almost any format and provides it to HMOs in Microsoft and web-compatible formats.
Health Decisions has found that the contractual relationship that exists between many HMOs and their provider networks represents a significant advantage in claim recovery collection.
Because Health Decisions is at the cutting edge of technology we can help HMOs 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.
Most HMOs have claim recovery efforts in place for subrogation or other areas. Health Decisions does not disrupt these existing relationships. We pursue only those claims not already identified by existing recovery efforts, which typically returns 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 is not the payor’s responsibility.
Our HMO clients select the level of involvement desired. Health Decisions can train your staff to do recovery internally and license our Claim Recovery Software Suite for your use. For those clients with recovery efforts in place, we will coordinate with these efforts and avoid duplication.
Many of the insurers working with Health Decisions use our service as part of their Continuous Quality Improvement program.