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MEDICAL REVIEW

  • BMI-HealthPlans works closely with our in-house Medical review company, HealthReview. We are also associated with various utilization review medical companies which specialize in medical necessity determination, pre-certification, medical post service reviews and case management. Physicians and registered nurses are available to personally consult with patients and family.
  • These medical professionals often serve as an educational source to providers on nationally based medical criteria, as well as the availability of PPO services. The patient and their physician will be free to make all clinical decisions regarding the admission, treatment and discharge of patients under a provider's care.

In House Utilization and Out of Network Negotiations – HealthReview

With the cost of health care continually rising, one way to lower cost of healthcare expenses is through direct out-of-network negotiations. Claims incurred by plan members with out-of-network providers render little or no savings without effective negotiations.

BMI-HealthPlans offers an effective and proven solution through our in-house Medical Review and Utilization Review Company - HealthReview. BMI-HealthPlans works with various out-of-network negotiation companies who negotiate out-of-network (Non-PPO) claims. These various companies charge a percentage of savings, usually between 20%-30% of the savings for discounts obtained through the negotiation process or contract. We have often found that out-of-network providers, including specialty providers, will not contract directly with PPO’s or negotiation companies. Our negotiating team at HealthReview can contact out-of-network and specialty providers in order to negotiate directly on a case by case basis. HealthReview has received favorable feedback and results from providers who typically are willing to negotiate discounts ranging from 10% - 60% of savings on a case by case basis.

BMI-HealthPlans is proposing the use of its in-house UR, HealthReview to negotiate discounts on behalf of your plan members for the out-of-network (Non-PPO) claims. Your plan can receive greater savings than what might be obtained through the various out-of-network negotiation vendors we work with. HealthReview charges a 15% of savings for discounts gained through negotiations. As noted above, 15% is considerably less than the industry standard of 20%-30% and results in a significant cost savings from what most negotiation companies charge. The negotiation process incorporates a line by line review of charges by HealthReview’s medical and clinical negotiations team.