Reference Based Pricing Support

Some employers have adopted cost structures based on Medicare. While most employers of have seen significant savings, the health insurance and health care process does become more complicated in an already complicated system.

Synergy’s Case Management Program can help the employer maintain their savings while significantly reducing the issues that naturally come with all reference based pricing programs.

While there are other advocate/navigation services to choose from, Synergy’s approach does not rely on the employee making the first step to ask for help.

Why Synergy:

Approach

Proactive approach that searches for the issues before they become major problems.

Certified Case Managers

The Nurse Advocate is a Registered Nurse and Experienced Case Manager.  Their training and experience allows them to work through issues on bills and medical access that frankly customer service individuals could not resolve as effectively or in many cases with no resolution.

Dedicated Advocate

The employer has one dedicated Nurse Advocate that allows for continuity and accountability to members and the employer.

Access

Our Nurse Advocates have access to the precertification company, TPA, RBP vendor, broker, employer and the member.  Most issues the employee may have can on the plan can typically be resolved by their Advocate.

Main Areas of support provided to the employee and employer:

Claim Support
  • Review of precertification notices to reach out to members that may need help.
  • Review non-network paid claims for potential balance billing.
  • Review hospital and non-network repricing reports to reach out to members that have seen a provider that typically balance bills.
  • Provide feedback and support to members with claims currently in dispute or negotiations.
  • Help facilitate credit letters to members potentially going to collections.
  • Negotiate non-hospital claims for payment on behalf of the employer and member.
Provider Network Support
  • Help members find in-network providers.
  • If in PHCS network, confirm PHCS network status for member due to inaccurate website status and provide support when front desk staff when they refuse ID card as non-network.
  • Facilitate non-network providers to join PHCS or facilitate a direct provider agreement.
Day of Service Support
  • With the complexity of Reference Based Pricing, things can go wrong on the day of service. Often it is a result of the provider or member being confused on how the program works.  Nurse Advocate works so that the employee receives the health care services as scheduled.
  • Synergy works with all parties to ensure member completes services as scheduled. Many employers provide cards to the members with their Nurse Advocates information.