By Steve McClung
It’s frightening to realize that after so many years of progress in the fight against cancer, we have seen tremendous improvements in treatment, great reductions in mortality and yet we are facing a significant rise in incidence. Treatments have improved but resulting costs have skyrocketed. Cancer diagnoses are also “increasingly shifting from older to middle-aged individuals,” according to a report by The American Cancer Society. This shift in trends means more people in the workforce face the risk of cancer diagnosis.
An abundance of point solutions exist to help with managing these costs, they help channel to centers of excellence, ensure treatment plans are in line with best practices and often help with site of care or medications. These are good options; this is lifesaving care, and it is essential. The unmanaged costs could easily put any health plan in a dire situation, in absence of other options, a point solution is a good plan.
A great solution would include all the aspects of a good point solution, but not focus on the disease, rather the person. As this study references, the human body is more complex, BMI plays a role as an underlying cause of cancer. Stress, genetics, mental disorders and a myriad of other factors have a role to play, everyone is different. Ideally a fully integrated solution would include an aspect for all the different factors, working together in an integrated fashion. A team of experts at the fingertips of the patient. Someone that could take the time to understand the individual and what factors are at play in their lives that may complicate or exacerbate their situation. Help them find alternative options, including treatments for the underlying conditions.
Hines has 36+ years of experience doing just that, last year our Oncology Case Managers in tight coordination with our Behavioral Health Team, our Health Coaches and Wellness Team and a wide range of other experts working in tandem saved our customers well over $11 Million, and touched the lives of 1400+ unique individuals.
Each of them needed more than just a point solution to help them through a time in their lives that was difficult not just because of their cancer care, but also for the impacts it had on their family, their mental well-being, and a myriad of other effects it had on their lives. Serving an organization that can provide this type of support for our customers is a tremendous honor, and I am proud to be a part of it.
Hines offers many specialized solutions for a spectrum of diseases, but here are just a few we might utilize to lessen the physical, emotional, and financial burdens of a cancer diagnosis:
Whether your members need to access quality healthcare around the world – or across the street – our Directional Care program makes sure they get the right care, at the right time, for the right cost:
- StandbyMDTM: An innovative AI-driven platform used to direct members to the Right Care at the Right Time in the Right Location and at the Right Cost.
- Encompasses telemedicine, visiting physicians, steerage into clinics and urgent care centers.
- Guiding members to quality, cost effective providers, including providers who offer competitive reimbursement agreements.
- Triggers effective cost management with upfront negotiations and bundled payments.
- Accessed through our 24/7 call center, through the StandbyMDTMapp or embedded in your member app with proven APIs.
Key to both member satisfaction and responsible cost control, Hines’ trusted Utilization Management services ensure all medical services meet the highest industry standards:
- Complete range of UM services, including Preadmission, Concurrent and Retrospective Reviews, Discharge Planning Support, Directional Channeling and Large Case Management.
- Inpatient medical, surgical, behavioral health and substance abuse stays.
- Outpatient services, surgeries, and procedures.
- Second Medical Opinion Assistance
- Gatekeeper Service for direct provider access, Exclusive Provider Organizations (EPO) or Narrow Networks
- Reference-based Pricing Partner Coordination
- 24/7/365 Nurse Line
Case Management can be challenging. Hines proudly offers one of the most comprehensive services on the market:
- Proactively working with members, their families, and their physicians, to coordinate the delivery of cost-effective quality care.
- Can be bundled with Hines’ UM services or implemented as a standalone solution.
- Specialty Complex Case Management, including oncology, transplant, renal/dialysis, high risk obstetrics, neonatal, and behavioral health.
- Chronic Condition Management including, Hepatitis C, Crohn’s, Hemophilia, MS and other large dollar or complex diagnoses.
- Specialty Pharmacy Management.
- Transplant Management.
- Upfront Negotiations.
Hines’ Out-Of-Network Solutions use a variety of approaches to make sure your costs remain competitive, so you can continue to provide your members with the healthcare they need:
- OON solution targets a “secured” competitive discount through an optimized blend of networks, direct contracts, and negotiations.
- Key differentiator: Our ability to successfully achieve this goal on over 90% of OON claims, virtually eliminating the opportunity for a provider appeal.
- If a competitive discount cannot be achieved through this blended and optimized approach, we can provide the option of utilizing a reference-based pricing methodology, or “Appropriate Payment” to secure a discount.
When it comes to Complex Claims Management, Hines combines multiple advantages to make sure things go as smoothly as possible:
- Dedicated Complex Claims Unit (CCU), composed of certified coding and financial experts, registered nurses and physicians, in-house legal counsel and seasoned negotiators who examine challenging claims in roundtable sessions.
- The CCU utilizes industry benchmarks to establish real costs and analyze the medical necessity of care rendered.
- Utilizing the results outlined in our Claim Check report, our team establishes fair market rates and negotiates a secured financial settlement with signed releases from the provider.
- Exceptionally skilled at identifying Fraud, Waste & Abuse (FWA)
Wellness, Prevention and Chronic Condition Management
Healthy Tomorrows by Hines™ – a comprehensive program which includes:
- Disease Management – A customizable solution for many conditions, including asthma, coronary artery disease, COPD, congestive heart failure, diabetes and rheumatoid arthritis.
- Wellness – Smoking cessation, health lessons, meal plans and our “connect to a coach” personalized service.
- Diabetic Management – Metabolic Syndrome and Pre-diabetes together with weight management program linked to our wellness services.
- Biometric Screening – Biometric / Lab Screenings available on-site or through your member’s Primary Care Physician.
- Health Risk Assessments – Either in conjunction with our Wellness program or as a stand-alone service.
Our team’s deep understanding of Behavioral Health ensures members are treated with compassion and dignity:
- High levels of education in addition to industry-recognized specialized certifications.
- Services are also sub-specialized within the team to provide high impact clinical expertise for your members.
- When indicated, access board-certified specialists actively practicing in the indicated behavioral health field.
Hines’ multi-level support, developed through decades of success, offer better savings – with less hassle:
- 40 professional full-time negotiators that lead the market in successfully negotiating in-network and out-of-network claims.
- With an average individual tenure of 12+ years, our fee negotiation team is well equipped with the experience, expertise and data required to conduct successful negotiations with provider signoff for greater savings and minimal noise.
We offer three levels of negotiation support:
- Our FLN negotiators support a highly automated process for lower dollar claims.
- Our second level of negotiation support focuses on inpatient and outpatient claims.
- Complex Claims Unit (CCU) composes our third level of support.
To speak to a Hines representative about our entire suite of healthcare solutions for your clients and members, please visit hinesassoc.com/contact or email Robert Marcoux at bmarcoux@hinesassoc.com
Further reading: https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21820
