Cost containment and more

Summit Re recently entered into an agreement with National Care Network (NCN) for its medical cost containment services. NCN’s core solutions for out-of-network claims include Fee Negotiations, Supplemental Network Repricing, and Hospital Detail Analysis, a Medicare-based pricing methodology.

Unmet Needs

While NCN had been extremely successful in saving its clients millions of dollars with these products, it realized that neither NCN nor other cost containment companies were doing enough to reduce overall healthcare charges. A new product was needed, a product which would:

• Allow fair reimbursement based on the facility’s costs to provide care
• Benchmark similar facilities reflecting the variances within facility costs
• Use flexible pricing methods to meet clients’ needs
• Recommend pricing that is transparent to the payer, provider and member

Data iSight

After a year and a half in development with Data Advantage, a company NCN acquired in 2005, NCN recently introduced Data iSight to meet all of those needs. Data iSight will generate fair reimbursement recommendations that generate legitimate savings. To do this, Data iSight leverages nationally recognized data sets to enhance provider understanding and acceptance; reviews both the financial and clinical components of a claim; incorporates cost-based awareness; and provides a transparency component for providers, payers and members.

About NCN

NCN, a privately held organization based in Irving, Texas, provides its services to large insurance carriers, self-funded organizations, third party administrators, HMOs, employer groups and reinsurance carriers across the country. NCN has achieved many milestones in its fourteen years of operation, including being the first in its industry to receive the URAC Core Accreditation, establishing HIPAA compliant EDI transactions, developing on-line tools for client access of claim tracking and reporting, and reviewing billions of dollars in medical charges.

NCN provides you with a dedicated team to ensure success in helping you meet your savings objectives. Visit NCN at its website, www.nationalcarenetwork.com, or contact Debbie Stubbs, RN, MS, CCM at Summit Re, 260-407-3979.

Survey: Managed Care Programs Accessed by HMOs

To ensure that our services match the needs of our clients, we conducted a survey shortly after forming Summit ReSources. The purpose of the survey was to determine our clients’ satisfaction with the managed care vendors they had been accessing prior to the formation of Summit ReSources.  We also wanted feedback as to what types of managed care vendors would be most beneficial. Many of our clients were also contacted by phone or in person to determine what types of managed care programs they currently have in place. All clients have some form of utilization management, consisting of preauthorization for admissions and certain other services, and concurrent review of inpatient admissions.

Disease management programs are primarily internally developed and  focus on the diseases most prevalent within the particular health plan. The sophistication of the programs varies, as well as the degree of outcome reporting. Few health plans have a specific end stage renal disease program, which may be needed in the future.

Almost all clients have contracts with pharmacy benefit managers, which may include reduced pricing for high-cost specialty pharmaceuticals, or they have contracts with separate companies for those drugs. The contracts provide discounts off of the average wholesale prices of the drugs. Some companies also include supplies and home nursing (when medically indicated) as a part of the contracts.

The majority of Summit Re clients  access United Resource Networks (URN) for transplant services and are satisfied with the services provided.

Approximately 25% of our clients have contracted with a neonatal intensive care unit (NICU) management vendor.

About half have some form of out-of-network repricing. Price negotiations are done internally for some health plans or contracted out to a national PPO/repricing vendor.

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Did you know?

• URN access fees for transplant services may be submitted as a reinsurance claim expense if the member reaches the reinsurance deductible.
• NICU management fees for programs accessed through Summit ReSources are eligible claim expenses if the member reaches the reinsurance deductible.

Summit ReSources: Make It Your Managed Care Resource

Summit Re established its own managed care department, Summit ReSources, to give you  access to a comprehensive portfolio of services, specifically designed to reduce costs while improving quality of care. The primary goal of Summit ReSources is to be your managed care resource. Consultative Case Management

We are available for consultative case management which includes, but is not limited to, assessment and recommendations regarding utilization, disease and case management programs, access to external managed care vendors at preferred prices, catastrophic case discussions, specialty pharmacy issues and out of area solutions. There is no additional cost for accessing our consultative case management service.

Educational Resources

Summit ReSources has access to a variety of educational opportunities and information about medical management. As information becomes available, we share it with you.

Portfolio

A portfolio of services has been negotiated to help you manage your claims. They include:

Transplant Management

National PPO Network

Non-network Claims Management

Catastrophic Injury/Illness

Recovery/Coordination of Benefits

Neonatal Intensive Care Management

Predictive Modeling

Chronic Disease Management

Summit ReSources was created in September of 2004.  Debbie Stubbs is the primary contact and Laura Pearce is Debbie’s backup for managed care issues.  You will find more information about Summit ReSources on our website at www.summit-re.com/managedcare.asp.