Our Services

Medical Bill Review

We average a 15% reduction from annual billed charges by removing invalid and non-compliant charges prior to the application of a network contract.

Our review is performed by clinicians and coding experts with advanced certifications and degrees. We identify errors and non-compliant charges per federal, state and commercially accepted billing guidelines. We review claims for medical necessity and offer legal reviews regarding adherence to PPO contracts and plan documents. The end results of your partnership with HPC are Clean Claims that adhere to your Plan Docs and PPO contracts. This results in an overall reduction in plan cost through the reduction of errors.

Specifically, we look for items that are non-compliant with the following:

• Social Security Act

• Code of Federal Regulations

• Uniform Billing Act

• False Claims Act

• CMS Manuals

• State Laws

• National AMA and AHA Rules & Guidelines

HPC Advantage

The best clinical and financial outcome for both you and your members.

The HPC Advantage program identifies high risk claims and matches them with a specialty network contract or other savings methodology provided by centers of excellence or other high-quality providers.  The result is an improved outcome for the patient, the provider, and the plan without provider pushback.

Key Services and Specialty Contracts:
• In network transplant claim review
• CART Therapy
• Pre-post stem cell transplant chemo
• LVAD implant and maintenance
• Hemophilia-Factor Replacement Therapy
• Dialysis
• Cancer / Oncology (including large discounts at Cancer Treatment Centers of America)
• Congenital Heart Defects (preemies and adults)
• Single Case Agreements
• Large in and out of network claims
• Bill review and negotiations

The HPC team of experts will “mine” your precert, case management and other reports to find high risk claims. Then we will scour our extensive list of specialty network contracts to find the best case rate or per diem contract for that claimant. Not all patient’s cases fit within every specialty case rate or per diem contract. HPC will close these “savings gaps” and mitigate plan costs by recommending other savings methodologies such as bill review and negotiations.

Allowing HPC to shop our extensive network of specialty network contracts will ensure that you have the best solution in place with minimal effort because we do all the “heavy lifting” for you.

Claim Editing

Our editing product utilizes advanced clinical editing technology to ensure that both institutional and professional claims are properly coded and compliant with applicable payer requirements.

• Cloud Based

• EDI, Desktop Apps, SaaS or Web Service Delivery

• EDI in almost any Format (837,Excel, Access, Proprietary Text, etc.)

• Rules and Logic Updated Weekly*

• Customizable by Group, Provider, Codes and Geo

• User Defined Rules

• Real-Time Reporting

• Flexible Pricing Structures Including Self-Pay Models

• Commercial, Medicare, Medicare Advantage and Medicaid

Our experienced negotiation team utilizes numerous tactics to reduce the cost of each claim. If a reasonable price for the reviewed service is not attainable through negotiation, we escalate the claim to a compliance audit. Our ultimate goal is to “train” your providers to charge the right price the first time. Every negotiated discount is secured by sign off.

Our reference-based pricing solution is completely automated and offers plan flexibility. Every year, reference based pricing becomes more and more accepted by providers in every state.

• Out of Network only, OON and Facility, or Complete RBP solution (including professional claims)

• Medicare rates on mature solution

• Multiple “flavors” of RBP to fit your groups and structure

• Management of multiple RBP vendors

• Training of groups and employees

• “Turn Key” solutions