Solutions

Post-Treatment

Opus 360 offers a wide range of customizable Post-Treatment solutions, including First Line Negotiations, Primary Network Access, Out-of-Network Solutions, Negotiations, Complex Claims Management and Reporting.

Designed to provide you and your members with both flexibility and convenience, Opus360 Post-Treatment solutions ensure your costs remain very competitive.

First Line Negotiations

With decades of experience and success, Hines’ First Line Negotiations offer you the satisfaction of better rates, without the hassle of network contracting:

  • First Line Negotiations (FLN) can be utilized as an alternative to a contracted primary network
  • FLN is comprised of a highly scalable team that negotiates rates with providers, regardless of dollar threshold, as a network replacement option
  • Building impromptu provider agreements that leverage case specific or patient specific agreements, as a network alternative

Primary Network Access

Developing a provider network is tough work. Hines’ Primary Network Access offers you a vast selection of various network types, tailored to your needs:

  • Using a detailed analysis of your demographics and claims history, we recommend an optimal primary network solution, as well as an out-of-area network solution, to optimize savings and ensure access to preferred providers
  • Delivers maximum value in assessing the quality of a network through detailed claims analytics, including quality of care and cost-based benchmarking
  • Currently working with 110+ regional and national PPOs

Out-of-Network Solutions

Hines’ Out-Of-Network Solutions use a variety of approaches to make sure your costs remain competitive, so you can continue to provide your patients 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

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

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 CareChex 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)

Reporting

Our approach to reporting is transparent, and provides you with a global vision of the process, equipping you to make the best decisions possible:

  • Access to free, real-time, online reporting for all Healthcare Management Services, including monthly Case Management Reports
  • Our Value-Based Reporting strategy supports all plan efforts
  • Benchmarked performance using Medicare, UCR, and other rates for financial analysis
  • Our consultative approach to reporting provides you with the information necessary to make the best decisions to control your healthcare costs, while providing a top quality healthcare plan for your members
  • Shock Loss Research Reporting