Join us in beautiful Las Vegas for HCAA’s Executive Forum ’25!
To reach out to our team please message Bob at bmarcoux@hinesassoc.com or Heather at hschaffer@hinesassoc.com
Stop by Table 22 to discuss Hines’ solutions to self-funded benefits and learn how we are moving healthcare forward!
Here are just a few of our industry leading solutions for health plans:
Utilization Management
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
Specialized Case Management
Case Management can be challenging. Hines proudly offers one of the most comprehensive services on the market:
• Pro-actively 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
Complex Claims Management
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 round-table 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)
Negotiations
Hines’ multi-level support, developed through decades of success, offer better savings – with less hassle:
• 40 professional full-time negotiators that leads 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
Wellness, Prevention and Chronic Condition Management
Hines’ Healthy Tomorrows™ – 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
