The burden of claims processing is difficult. Satisfying all of the ancillary needs necessary to make a policy solvent can be more than the claims process can bear. SANUS HEALTH has created solutions to questions such as:
1. Is there a program that permits carriers to control their own claims process while eliminating all of the concerns associated with provider related costs?
2. How can we make sure that we are getting the best in “provider management” from the start of a claim?
3. Can we reduce the cost of processing and keep control of those processing parameters that are so important to my bottom line and policyholder satisfaction?
Getting started is as easy as picking up the phone. First, we can analyze your current claims program. Next, we’ll tailor a claims management program to fit your company’s specific needs. Our services range from independent claims adjusting to providing third-party administration for self-insured organizations. We’ll work with you to determine the right fit for your company. And with our customized system in place, you can rest assured that your claims reports will be accurate and on time and in line with what your plan was made to deliver to both the policyholder and the carrier. Feel free to contact us any time for inquiries on customer satisfaction.
If there is a specialty of the house, it is Repricing. Our decades of operational experience in both the US and International claims arena has enabled us to provide the strongest Repricing support in the industry. Coupled to this support structure are:
* Expert Technical Support, service and professional ethics
* Fast, accurate provider management and reporting
* 24 Hour Service, following notification of claim
* 50 years of insurance Repricing experience
The SANUS HEALTH network is comprised of several National and International PPO’s and employs a substantial direct contract network throughout its primary service areas. We are currently in all 50 states, Canada, the Caribbean and Latin America.
SANUS HEALTH takes pride in its efforts to direct our clients’ members to providers who participate in The SANUS HEALTH Network. We use a variety of measures to make members aware of the hospitals, primary care physicians, specialists, freestanding X-ray, ambulatory surgery centers and other types of ancillary health care professionals that are available. We channel members to network providers when they contact us by telephone. Provider information also is made available in print and through access to electronic directories when compatible. In addition, participating providers have 24 hour access to our provider referral service so they can refer members to participating hospitals, specialists and ancillary health providers when medically appropriate.
SANUS HEALTH requires that The SANUS HEALTH Network be referenced on member ID cards, on group health explanations of benefits and carrier referral sheets when available. We also require our clients to utilize benefit plan incentives to encourage the use of contracted providers and we provide members, communication materials that clearly outline the advantages of using network providers.
SANUS HEALTH clients who have access to the network include various group health, managed care and compensation payers such as:
* International employers
* International Insurance carriers
* National and International Third Party Administrators (TPA’s)
We offer value to our network clients by prospectively channeling members through a variety of means, including:
* Requiring benefit plan incentives
* Telephonic and site provider directories
* Communication materials
* I.D. cards
* Redirection if required during the utilization management process.
* Hassle-free administrative procedures
* Standardized billing statements.
* An Experienced clinical management staff of medical professionals
* Professional provider relations unit for rapid response to concerns
* More than 7,200 Hospitals.
* Network Databases with more than 3,350,000 medical specialists.
SANUS HEALTH has configured a wide array of utilization management programs to serve the interests of health insurance companies, third party administrators, employer "self-funded" plans, hospital business offices, medical practices, reinsurance carriers and the legal profession. Because we interface with both carriers and providers we are thoroughly versed in those processes that clearly maximize results for our clients.
We pride ourselves on our commitment to quality of service. Our professional audit and case management personnel have acquired the Associate, Customer Service (ACS) designation, sponsored by Life Office Management Association (LOMA). LOMA provides one of the leading insurance specific educational programs in the industry today, encompassing topics such as Operations, Administration, Legal Aspects of Life and Health Insurance, Accounting, Information Systems, Profitability and Solvency, Reinsurance, and Regulatory Compliance.
Our flexible fee schedules are built to provide any potential user with a rate structure to meet their project needs. Our services and fees can be tailored to provide hourly, project, or incentive-based fee structures. SANUS HEALTH has included a variety of case management processes to better assist you with your specific medical concern including the below:
SANUS HEALTH has established an extensive system of criteria so that potentially large claims are recognized early. SANUS HEALTH then begins a review of the case and determines needs in terms of managed care. Our registered nurses negotiate pricing, contact on-site managers, ensure that the physician’s plans of treatment are being administered correctly, and monitor billing. Our case managers and claims examiners know your Plan benefits and requirements and provide an invaluable coordination of these requirements with the health care providers.
On Site Case Management includes:
* Standard Patient visits to hospital/rehab facility
* Record Review for criteria compliance
* Participation with patient case conference
* Discharge Planning Home health care arrangement
* Durable Medical Equipment arrangement
* Home visits to patient (if needed)
* Report preparation
* On-site Case Management (in or out of area)
* Telephonic Case Management
* Elite (VIP or “special” patients programs)
* Accompany patient to physician visits
* Assistance with short or long term housing
* Acquisition of medical records, x-rays, etc.
* Assist patient with errands
SANUS HEALTH offers a total package Utilization Review program, specifically tailored to include the 2 most important areas of UR.
Pre-admission Review and Certification
The objective of this process is to reduce expenditures for in-patient acute care by monitoring the utilization of in-patient hospital care and offering patients appropriate alternative services. This process includes:
* Notification of admission by employee, hospital, or physician
* Notification in writing of criteria met and approved
* Referral to Case Management
* Referral to physician reviewer
* Concurrent Review and Discharge Planning.
* SANUS HEALTH will continue to monitor an in-patient’s hospital stay to verify medical criteria of hospital days. Planning for discharge is an integral component of the concurrent review process. Step-down units, home health, and outpatient physical therapy are among the alternatives open to a patient upon discharge.
* Certification of additional days
* Physician referral if not certified or non-par
* Denial and appeal if appropriate
* Referral to case management
Retrospective utilization reviews are also conducted to ensure that the services provided were necessary and treatments were reasonable and customary both as to the amount paid and discounted as well as the appropriateness of care. The results of the review are then reported to the providers. Appropriate steps are taken to mediate discrepancies so that balance billing of the participant is prevented.
Whether you’re insured, uninsured or self-insured, SANUS HEALTH can help audit your bills and save you money you thought you didn’t have. We can cut health care costs and lower the overall cost of operation for any organization.
Commonly, insurance carriers do not perform the same kind of auditing we do as SANUS HEALTH goes through your chart with a fine toothcomb in order to save you or your company hard earned money. Most carriers don’t have the time, expertise or personnel to do the job properly. SANUS HEALTH can also provide other prospective services for prevention of diseases and maintenance of good health, reducing your dependence on future health treatment. SANUS HEALTH will provide you with information and tips as well, to save money during hospitalization. In doing so, we can help decrease your health care cost and maintain your profitability.
Medical Bill Audit
At SANUS HEALTH our audit goal is to assure that policyholders receive the services for which they are charged. We are not concerned with other issues when performing an audit for the purpose of determining a correct bill, because we have already determined whether or not appropriate medical treatment was given.
SANUS HEALTH’s only concern while performing this audit is whether or not the policyholder did indeed receive each item or service that appears on the bill and the necessity of each procedure. (We will audit bills up to but not older than 2 years.)
SANUS HEALTH will review the Chart for compliance of usual, customary and reasonable charges as well as inappropriate billing practices. Below are the areas covered in SANUS HEALTH’s review and audit of your medical bill.
* Charges exceeding the maximum allowed
* Up- Coding
* Unnecessary Ancillary Service
* Unbundling of Laboratory Tests
* Global Surgery Fees
* Double Billing
* Bilateral Surgeries
* Unrelated Diagnosis and Treatment
* Extended Length of Stay
* Errors in Room Charges
* Medication Errors and overcharges
* Medical Records Review
First, SANUS HEALTH organizes, tabulates and chronologically arranges the medical records in a logical fashion that is easy to follow and understand. This includes separating the contents by dates and occurrences, then providing a table of contents and separating them by volume if needed. SANUS HEALTH provides timely and detailed review followed by a concise report of the findings. We‘ll identify causation, recommend potential options, and review hospital policies and procedures.
DOCUMENTATION OF AUDIT/MEDICAL REVIEW
SANUS HEALTH provides a detailed hard copy report, reflecting identified discrepancies, which have been discussed with Hospital/agency for discounts and/or reductions in Hospital Bills, or a detailed medical record summary report if a medical record review is performed. As trained Hospital Analysts, we take all the mystery out of checking your bills, or reviewing records for appropriate medical care. We know how and where these errors occur and can assist you in reducing and/or recovering these overcharges, and/or evaluating whether the medical care and treatment received was justified and appropriate.
SPECIALIZED REPORTING CAPABILITIES
SANUS HEALTH utilizes a modular system that permits immediate generation of more than 200 specific reports for insurance carriers, reinsurers, third party administrators, and networks. This broad range of capabilities permits SANUS HEALTH to configure client reports to their requested specifications.
Reports range from eligibility information on covered individuals through the result of claims processing. Intended audiences include, employers, medical providers, provider networks, insurers, reinsurers, and government agencies. Most importantly we can easily create custom reports to meet your information and analysis needs.
The matrix of consulting services offered by SANUS HEALTH has been carefully designed to build upon the core set of competencies of its staff and the expressed needs of our customers. SANUS HEALTH has more than 170 years of combined experience in the indemnity, group and managed care arenas with some of the largest managed care and health care providers.
- Insurance Consulting
- Cost Reduction Strategies
- Analysis of Healthcare Renewals/Negotiations
- Negotiating Year-End Accounting
- Health Care Data Analysis
- Healthcare Benefits Cost Analysis
- Medical Outcome Assessment and Data Analysis
- Evaluation of Provider Reimbursement Systems
- Healthcare Plan Evaluation
- Funding Arrangements Evaluation
- Accountability & Performance Program Design
- Health Care Provider Services
- Competitive Analysis
- Managed Care Contract Analysis
- Managed Care Network Development
- Specialty Network Evaluation
- Provider Reimbursement Schedule Development
- Product Design and Product Positioning
- Claim Reserve Analysis and Certification
- Plan & Policy Design
- Managed Care Plan Design/Selection/Negotiation
- Design of Health Plan Utilization Incentives
- 24 – Hour Managed Care Program Design
- Disease Management
- Reserve Determination
- Managed Care Education
- Staff seminars
- Provider In-service
Verifying eligibility is something all carriers or their service counterparts must undertake. SANUS HEALTH systems provides a process that is easy to use, incorporates 1-800 number access, reduces phone costs associated with verification and staff time required to complete the process, and all at an inexpensive rate.
Eliminate the time and frustration of having to conduct calls, verify discrepancies, fax information to providers while being cut off, put on hold, transferred or told that the provider did not receive the information. The SANUS HEALTH systems eligibility program permits your providers to call in and verify while keeping an electronic record of each call, what was verified and all the specifics of this interface.