MultiPlan's PHCS Network is the only independently-contracted primary PPO network to have been Accredited by NCQA for credentialing – a status we’ve held continuously since 2001. PHCS Network is available in a variety of configurations including outside the plan service area, to extend local HMO or PPO coverage nationally.
NCQA has reviewed and Accredited the PHCS Network’s Credentialing functions only. For complete details on the scope of this review, visit www.ncqa.org
A spinal fusion procedure billed at $42,452 was reduced by bill review to $24,956. Payment integrity analysis determined that a spinal fusion and lumbar laminectomy were separately billed. Citing CPT Assistant, American Association of Neurosurgeons and the NCCI manual, the lumbar laminectomy is included in the spinal fusion if performed at the same spinal level, and is only as extensive as necessary to prepare the site for the fusion.
After discussion with the provider, the bill was reduced, with provider signoff, by an additional $5,852.
CEO, Medicare Advantage plan
49 hours of critical care time ...
billed for a single day.
Smoking cessation counseling services ...
billed for a four-year old patient.
Patient visits ER for a dislocated shoulder ...
at 10 different hospitals in 2 months.
Provider self-service to encourage routine updates
Predictive data cleansing through sophisticated data mining
Full time employed, U.S.-based outbound call center
Placement of a gastric restrictive lap band . . .
reported with a total gastrectomy (removal of stomach)
Breast reconstruction surgery . . .
reported with revision of breast reconstruction on the same day
Physical therapist reports the same services on every bill . . .
for every patient
An urban teaching hospital with 150-300 beds submitted a $27,268 claim for a Cesarean Section. Data iSight analysis determined the charges to be 364% of the hospital’s cost to deliver the service.
Using its patented benchmarking methodology, Data iSight compared the claim to 103,212 claims with the same APR-DRG and severity level from 266 other urban teaching hospitals of the same size. The median, wage adjusted cost of the benchmark group was $5,384. Data iSight recommended a reimbursement at which 75% of the facilities in the benchmark group would be profitable, generating a 47% discount and a reasonable profit to the hospital.