CLAIMS NEGOTIATIONS

Penfield's negotiators use evidence based criteria to ensure a reasonable reimbursement to the healthcare provider.  An assessment is performed on both the claims and the provider and benchmarked against industry data.  Each successful negotiation comes with a provider sign-off to protect our clients from any appeals.

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MEDICAL BILL REVIEW

Our medical bill review program takes a hands on approach to finding errors. Algorithms provide efficiency but they are no substitute for a professional coder doing a line by line review. Because we go the extra mile we find what the algorithms overlook. Our nurses review each episode of care for clinical correctness, medical necessity and experimental and investigative treatment. All of our findings are brought to the provider's attention and are negotiated. We believe that a negotiated solution delivers the best value and peace of mind through closure.

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CASE MANAGEMENT

Ensuring the most effective delivery of care and monitoring over utilization is a significant component of our medical cost containment strategy.  Our nurses and medical director use industry care guidelines to determine the most effective delivery of care is achieved.  Our number one objective is the care of the member and getting them back home for the continuance of care.

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PROVIDER NETWORK

Penfield provides access to a vast health provider network of physician, hospital, clinic, surgery center and prescription network.  The network is comprised of regional and national PPOs, HMOs and direct relationships.

Our objective is always to bring you the best net savings

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DIRECTIONAL CARE

One of our unique cost containment strategies includes our ability to direct members to appropriate healthcare providers who rank high in quality for that given specialty and jurisdiction.  Our directional software will also determine the best cost outcome amongst these providers so that our members are receiving the best level of care at a reasonable cost.

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REFERENCE BASEd

From full replacement to any of the RBP variations, Penfield has the data and processes to reprice claims smoothly and take the sting out of balance billings.  By blending cost and quality data into negotiated settlements before members receive care, Penfield's RBR programs provide a softer more manageable approach that delivers high service and high value. 

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