Out of network claims

Repricing Optimizers Suite:

The second suite of services comprising TC³'s integrated Loss Control Technologies is our Repricing Optimizer Suite. The services provided through this suite focus on 1) quickly and efficiently increasing PPO savings for payers by combining technology with access to 600,000+ providers to reprice retail claims, increasing PPO savings by 10 – 25% and 2) using proprietary data sets and benchmarks to establish reimbursement on retail claims and determine the appropriateness of charges, reducing claims by 1 – 3%. These tools are designed to supplement out-of-area coverage to address network gaps with existing provider networks and reduce the cost of out of network claims.

AccessPlus PPO Networks
Increase Network Savings Without Changing Benefit Plan

Out of network claims are an expensive fact of life for all healthcare payers. TC³ AccessPlus PPO Network increases PPO savings for payers without changing plan design or benefit differentials. AccessPlus is designed to supplement out-of-area coverage to address network gaps with existing provider networks. AccessPlus provides payers with a tool to reduce the cost of out of network claims by supplementing their current PPO networks. TC³ has developed strategic relationships with national, regional and local networks to bring a customized network management solution to our clients that include access to over 4,500 hospitals and 700,000 total providers.

AccessPlus satisfies out of network claims repricing needs for healthcare payers by supplementing the plan’s service offering with access to the nation’s largest aggregated PPO network. The AccessPlus Network includes national access to hospital, physician (including specialist) and ancillary providers such as home health and DME.

AccessPlus PPO Features & Benefits

• Access to PPO discounts to over 700,000 provider locations.

• Customized network configurations to optimize network penetration and savings.

• Single source, streamlined repricing process through EDI connectivity.

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95+% of out of network claims repriced within 24 hours.

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No minimum claim dollar threshold.

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EDI repricing improves claims flow, repricing turn around time and accuracy.

Provider R&C Benchmarking
Settle Claims Utilizing Benchmarking

TC³ accesses multiple data sets to determine and benchmark the appropriateness of the charges for each confinement or procedure and negotiates each claim directly with the providers. The data sets include key cost-to-charge ratios, which are the basis for calculating reasonable and appropriate reimbursements on hospital claims.

Utilizing these data sets to negotiate claims for charge appropriateness sets TC³ far apart from prompt pay discount organizations. TC³’s R & C Negotiation Services apply to all types of claims, including inpatient, outpatient, physician, IV therapy, and other specialty claims (e.g. dialysis, DME). All negotiated settlements include provider sign-offs or written documentation indicating no balance billing to the member.

Provider R&C Negotiations Features & Benefits

•	Cost-to-charge data establishes baseline for reasonable reimbursement.
•	Negotiate from net cost up rather than billed charge down.
•	Claims routing by success rates maximizes savings.
•	Not a prompt pay discount negotiation.
•	Provider sign-off with no balance billing to the member.