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Provider Selection

The Provider Selection solution enables health plans to improve their claims payment accuracy. It automates the selection of the right provider, the right contract and the right reimbursement method for all services in an incoming claim. The shift to 5010 and the prevalence of overlapping payment arrangements are increasing the complexity of provider selection. MHS’s configurable provider selection logic adapts to complex provider relationship hierarchies and reimbursement methodologies.

Business Challenges:

• The shift to HIPAA 5010 mandating the use of NPIs instead of plan supplied IDs
• Product, care model and payment innovation driving complex, overlapping reimbursement arrangements
• Regulatory and provider pressure for detailed explanation of payments
• Increasing cost of provider payment disputes
• Cost of overpayments to providers

Key Features:

• Real time, very high throughput, and rules driven provider selection and verification
• Visual configuration of selection rules to facilitate business user transparency
• Configurable, low impact audit to enrich EOPs and drive continuous improvement
• Support for granular provider rate differentiation including network and contract-level precedence
• Support for complex provider relationship hierarchies and reimbursement methodologies, such as PCMH, ACO, Client Specific Pricing, etc.
• Probabilistic matching to compensate for poor data quality
• Support for alias for provider names and locations
• Enterprise scale features for scaling and manageability

Key Benefits:

• Enables the usage of the optimal payment mix to drive desired provider performance
• Decreased medical expenditure through greater claims payment accuracy
• Improved auto-adjudication
• Reduced the volume and cost of provider payment disputes
• Increased reimbursement transparency through enablement of enriched EOPs
• Increased provider satisfaction
• Audit patterns could be leveraged for fraud analysis