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Solutions

It is estimated that over $60 billion a year is lost to waste, fraud and abuse in the health care industry.

Solutions

The most common areas include durable medical equipment (DME), prosthetics, orthotics, supplies and home health care.

Our unique and groundbreaking Ancillary Benefits Management (ABM) program prevents waste, fraud and abuse in these areas by delivering real-time processing of these ancillary products and services, prior to fulfillment. That means health plans have visibility into what products and services are prescribed at the time of referral, before the product or service is provided.

Our solutions prevent fraud, waste and abuse before it even happens.

The Healthelinx ABM program provides a centralized way to control the quality and costs of products and services obtained through contracted ancillary providers.

The program consolidates all referral, billing and payment processing onto a single platform, with a single point of contact, to eliminate the complexities so often experienced by those who must manage multiple vendor relationships. The entire claims process is automated to eliminate manual administrative tasks and all services are prospectively adjudicated prior to fulfillment.

Solutions

We deliver innovative solutions that eliminate complexities.

Prospective adjudication with real-time processing and data exchange confirms eligibility prior to any product or service being fulfilled. Our ABM program applies all business rules and edits at the time of referral, ensuring that the appropriate product/service is being provided and confirms the appropriate price.

Deliveries of all products/services are confirmed electronically and all bills are compared to the original referral for accuracy ensuring:

  • Correct units of measure
  • Accurate pricing
  • No duplicate bills
  • No add-ons and inappropriate auto shipments
  • No overpayments
  • No payments for products and services that were never provided

Our comprehensive and proprietary Master Coding System provides specific codification and pricing that’s 40 times more granular and detailed than standard HCPCS (Healthcare Common Procedure Coding System) for more than 90,000 coded items. All miscellaneous codes are redefined to identify the specific item, allowing for complete transparency of products and pricing. And, our industry-unique coding structure ensures appropriate pricing is applied for all products, leading to more accurate billing and the elimination of retrospective bill disputes.

Our utilization management tools ensure correct and consistent units of measure are used, appropriate pricing is applied, and a preferred product formulary is employed to enforce best pricing for the most appropriate product and/or service.

Our innovative program incorporates an advanced workflow process that allows for real-time adjudication and approval of ancillary products and services prior to fulfillment, through electronic data exchange with connected providers. This progressive system streamlines processes and manages costs by eliminating paper bills and standardizing billing codes.

This technologically advanced program delivers:

  • Accurate units of measure and appropriate pricing on every bill
  • A significant reduction in administrative burden
  • Accurate billing substantially reduces retrospective billing disputes (appeals rate)
  • Preferred product formulary drives down unit cost

Additional Features

Our real-time claims portal makes it easy for claims staff to manage authorizations, transactions, run reports and obtain actionable information.

An intuitive, dashboard-style interface allows for quick navigation and retrieval of the most relevant and timely information, allowing users to make immediate, informed decisions.

The claims portal can be customized with features such as client-defined workflow, program usability preferences and group-specific security roles to restrict access to confidential data.

 

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The Healthelinx ABM program is built on a centralized platform that provides a single point of contact between the payer and all contracted ancillary providers. The platform is highly scalable and completely customizable for each of our clients. And, it is designed to handle large processing environments and the high volume of transactions typically generated in a group health plan setting.

Electronically enforced protocols and business rules, customized for each health plan, allow us to streamline processes, manage costs and significantly reduce instances of fraud and abuse, all while ensuring the most appropriate patient care.

We simplify the management of multiple ancillary vendors. Our customers interface only with Healthelinx, streamlining the management of all ancillary vendors into one system in which pricing, workflow, billing and performance are managed.

Vendor benchmarking and comparison allows for increased competition and service levels.

The end result is better care
Solutions

The Healthelinx ABM program streamlines processes and manages costs by eliminating paper bills, standardizing billing codes, delivering benchmark and performance information, centralizing eligibility and enforcing claims workflow rules. The result is a more efficient workflow, optimized utilization of products and services, better service and care for claimants and greater savings for payers.