We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Corporate Information Why Choose PayerFusion? Expertise Over 75 years of combined experience on all sides of the healthcare business means there’s never a situation we can’t handle.
At PayerFusion, we “fuse” the gap between providers who deserve fair compensation for quality care and payers who seek to pay a fair price for medical services rendered. PayerFusion’s technology and methodology are powerful, information-driven tools that outperform the savings reported through the use of leased PPO networks for healthcare payers and insurers. Our proprietary network and patent-pending cost containment methodology leverages real cost and quality data using a unique algorithm to achieve superior reimbursement pricing. We provide a full range of healthcare plan administration and claims processing services to self-funded employers and international insurance companies with lives in the United States and other countries around the world. Compared to traditional approaches to cost containment, we effectively lower the cost per claim and the total cost of healthcare rendered in the country where care is provided. PayerFusion Holdings, LLC is the parent company of PayFuseNet, LLC, which contains the operations of our provider network, PayFuseNet. We are headquartered in Miami, Florida, with a satellite office in Copenhagen, Denmark.
Proprietary Provider Network We give patients individualized guidance to identify the best providers to care for them and their specific medical situation. Cost-Plus Methodology Our unique patent-pending cost containment methodology leverages real cost and quality data using our own unique algorithm to ensure that reimbursement pricing is fair to both payers and providers. Technology Driven Efficiency Our exclusive technology empowers payers and providers to reduce administrative burdens and ensures the timely sharing of information, prompt payment and less hassle for all. Compliance Each claim that we adjudicate is validated relative to regulatory and compliance guidelines to ensure viability of payment based on the requirements of federal and state guidelines.
For more information about PayerFusion please call +1 305-760-8739 or visit PayerFusion.com 5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Consideration of Care Setting Our goal is to help patients identify the right providers and the right type of facility to provide the most efficient and effective treatment. Outcomes are an important factor in considering facilities to ensure we direct patients to high performing providers. Value is essential in the care selection process – because data has shown that the most expensive care is not necessarily the best, and money can’t be wasted on ineffective care.
Outcomes We compare results and outcomes at various facilities to match patient needs and urgency with the nature of care and specialty required. We look beyond overall facility performance to identify outcomes for specific diagnoses to ensure that we identify the best performing facilities and physicians for specific patient and client needs.
Value and Costs We educate patients and make them a partner in wanting the best quality for the best value, because today’s charges are tomorrow’s premiums. If access is misused everyone loses – including the patient. PayerFusion identifies and suggests providers that have expertise in the relevant area(s) of care along with a record of superior outcomes and where we achieve pricing within defined benchmarks.
Our Team Delivers: Advocacy We ensure that patients get access to the care they need. Our services range from the ability to talk to the provider and explain benefits, to calling ahead to make sure the patient is accepted and welcomed to case management for the episode of care.
Expertise Over 75 years of combined experience on all sides of the healthcare business means there’s never a situation we can’t handle.
Knowledge We give patients the knowledge to seek and receive care in the best way possible.
For more information please contact us at +1 305-760-8739 or visit PayerFusion.com
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Cost-Plus Methodology PayerFusion’s superior and fair approach to reimbursement pricing Our patent-pending approach to cost containment ends the gaming that is epidemic in the U.S. healthcare system. Rather than pursuing discounts on ever-inflating prices, we leverage real cost and quality data, mined with our own unique algorithm to achieve superior and fair reimbursement pricing. Most importantly, year after year, we enable our clients to contain both their average cost per claim and their overall claims expense.
National Discharge Database Hospital L ocation Urban v. Rur al Geographic Region
Facility T ype Teaching Non-teaching
Bedsize C ategory 1 - 150 151- 300 300+
Each inpatient claim is compared to a benchmark group of similar clinical cases in “like” hospitals over the most recently available 24 months Wage index adjusted as assigned by the Centers for Medicare and Medicaid Services
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Claim Examples:
DRG: 149 - Disequilibrium Measures
Actual Results
Cost of Care Analysis
Actual Charges
$15,834
800%
Cost of Care
$1,910
600%
729%
400%
$6,500
200%
% Mark-up from Cost Payment to Provider % Mark-up from cost Gross Reduction % Gross Reduction
240% $9,334
201% Facility Mark up from Cost
$1,680
Net Cost of Claim
$8,180
Net Reduction
$7,654
Benchmark Mark up from Cost
Cost Plus Results
59%
PF Access Fee
% Net Reduction of Charges
0%
729%
12% PayerFusion Fees
29%
48%
Plus Mark-up
11%
54%
Cost of Care
DRG: 343 - Appendectomy w/o Complications Measures
Actual Results
Actual Charges
$27,006
Cost of Care
$4,688
% Mark-up from Cost Payment to Provider % Mark-up from cost Gross Reduction % Gross Reduction
476% $14,000 199%
500%
476%
400% 300% 200%
170%
100% 0%
Facility Mark up fr om Cost
Benchmark Mark up fr om Cost
$13,006 Cost Plus Results
48%
PF Access Fee
$2,081
Net Cost of Claim
$16,081
Net Reduction
$10,925
% Net Reduction of Charges
Cost of Care Analysis
40%
17% 40%
35% 8%
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
PayerFusion Fees Plus Mark-up Cost of Care
+1 305 760 8739 payerfusion.com info@payerfusion.com
Claim Examples:
DRG: 330 - Major Small & Large Bowel Procedures w/cc Measures
Actual Results
Cost of Care Analysis 220%
Actual Charges
$76,618
Cost of Care
$24,130
210%
218%
200%
% Mark-up from Cost Payment to Provider % Mark-up from cost Gross Reduction % Gross Reduction
218%
205%
$40,000
195%
66%
185%
196%
190% Facility Mark up fr om Cost
Benchmark Mark up fr om Cost
$36,618 Cost Plus Results
48%
PF Access Fee
$6,591
Net Cost of Claim
$46,591
Net Reduction
$30,027
% Net Reduction of Charges
215%
31% 39%
PayerFusion Fees
21%
9%
39%
Plus Mark-up Cost of Care
DRG: 559 - Malignant Breast Disorders w/o cc/mcc Measures
Actual Results
Actual Charges
$7,656
Cost of Care
$1,582
% Mark-up from Cost Payment to Provider % Mark-up from cost Gross Reduction % Gross Reduction PF Access Fee
384% $5,000 216% $2,656
450% 400% 350% 300% 250% 200% 150% 100% 50% 0%
384%
183%
Facility Mark up fr om Cost
$425 $5,425
Net Reduction
$2,231
Benchmark Mark up fr om Cost
Cost Plus Results
35%
Net Cost of Claim
% Net Reduction of Charges
Cost of Care Analysis
45% 5% 21%
29%
PayerFusion Fees Plus Mark-up Cost of Care
29%
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
PayfuseNet Our Provider Network
The Original “Network Without Walls”
Imagine a network where patients can go to any provider they want, knowing in advance which providers can best meet their needs – a network where insurers have the peace of mind of knowing that they will pay a fair price for quality service. At PayerFusion, we have transformed network access to provide patients with the freedom of choice and our provider recommendations (based on cost and quality) to eliminate guesswork, while ending the gaming of the system to chase discounts on ever-inflated prices. We anchor our cost reductions to the actual cost of services and an understanding of fair rates of reimbursement by services to be rendered, provider and geography. PayerFusion is a natural fit with insurers who provide open access plans – without the premium price. Our cost-plus methodology removes all network barriers because the reductions achieved are not contingent upon the providers’ network membership. Rather, they come from our unique approach to claims administration. Our international cost containment services range from card acceptance and direct billing to discounts on some claims. Network presence established in Puerto Rico, the Caribbean, Central (including Mexico) and South America,Eastern Europe, New Zealand, South Africa, and Turkey. Networks in development include Egypt, Turkey, India and China.
Our Team Delivers: Advocacy We ensure that patients get access to the care they need. We can coordinate care in advance or work with patients, providers and the insurer on the back-end to manage claims already incurred or in process. Expertise Over 75 years of combined experience on all sides of the healthcare business means there’s never a situation we can’t handle. Knowledge We give patients individualized guidance to identify the best providers to care for them and their specific medical situation. Your Branding Our clients have the opportunity to build their brand presence in the U.S. Compliance Each claim that we adjudicate is validated relative to regulatory and compliance guidelines to ensure viability of payment based on the requirements of federal and state guidelines.
For more information on our Medical Affiliate Provider Network please contact us at +1 305-760-8739 or visit PayerFusion.com 5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
PayFuseNet Lines of Business
Network Configuration
Provider Network • Physician • Hospitals • Vision • Dental • Pharmacy Others: • SNF (Skilled Nursing Facility) • HHA (Home Health Agencies)
Ambulatory Services Network • Ambulatory Surgical Centers • Urgent Care Centers • Clinics • House Calls
Virtual Medicine • Telemedicine • Inbound/Outbound • Second Medical Opinion • Office Visits • Consults • Mental Health • Disease Management
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Dental Network
Members can choose from over 137,000 dental practice locations nationwide. The PayerFusion Dental Network is provided as either a covered benefit or simply access to significant savings. We offer insurers and their members a reduced-fee dental program designed for consumers looking to maintain their oral health and minimize their dental care expenses.
Providers All network providers are independent contractors in private practice who are reviewed and credentialed to ensure adherence to quality standards. General dentists participating in the program have agreed to accept the contracted rate as payment in full for services performed. Specialists are easy to access in the network and provide discounts according to their individual fee schedules.
Member Benefits Participants in the Dental Discount Program will receive a membership card. If included as part of a medical insurance program, the dental ID will be included on the back of insured’s medical cards. Members can access dentists through PayerFusion’s Provider Search (myprovidersearch.com). We can coordinate appointments for members upon request to ensure a hassle-free experience. These discounts are available to members and their families throughout the dental network with no limit on usage. Enrollees arrange for needed dental care, including payment, directly with the network provider. Enrollees are responsible for the entire cost of the dental care provided. The discount program is NOT INSURANCE (although the network and savings can be incorporated into insurance plans with dental benefits). It is a reduced fee for service program that is designed to save your members money on most of their dental needs. Their final cost will depend upon the type of dental work performed as well as the geographic location. Fees for the dental work performed are due at the time service is rendered unless other arrangements are made with the dentist’s office. There are no out of network benefits payable in this program. The PayerFusion Dental Network discounts cannot be combined with any other discount dental program.
Dental Specialists available through our network: • Orthodontists • Periodontists • Oral Surgeons Wisdom teeth and major extractions • Prosthodontists Bridges and dentures • Pediatric Dentisits Treatment for children • Endodontist Extensive root canals
For more information on our Dental Network please contact us at +1 305-760-8739 or visit PayerFusion.com
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Pharmacy Network Our pharmacy network is extensive, our savings are significant, and our service is personalized. We can customize both coverage and member services to fit your needs, ranging from carve out networks to phone greetings with your company name. Pharmacy Discount Card Our Pharmacy Discount Card provides members with the option of enrolling and printing their cards online. On-demand distribution allows for members to travel throughout the U.S. prepared for any situation requiring them to purchase medication. The Pharmacy Discount Card is an easy add-on to existing policies as additional benefit.
Network Coverage:
• 45% average savings to client • No card numbers required • Massive distribution volume
Premiere Expatriate Services •
Complete Pharmacy Benefits Management (PBM) service, including customized services for generic and brand name medications.
•
Straight cash and carry discount card - minimum administrative burden.
•
• 40% independently owned pharmacies • 60% are national chains (example: CVS, Walgreens)
Mail-in Pharmacy Services - medications submitted and distributed via mail.
For more information on our Pharmacy Network please contact us at +1 305 760-8739 or visit PayerFusion.com.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Vision Network We provide access to top doctors, cutting-edge frame styles, and technologically advanced lab services. Our optometrists are Therapeutic Pharmaceutical Agent (TPA) certified and our ophthalmologists are American Board of Ophthalmology (ABO) certified. They are located nationwide in a variety of office settings and offer early morning, evening, and weekend appointments, while many accept walk-ins. They have a wide selection of frame brands, from classic styles to the latest in designer brands—making it easy for you to get your exam and eyewear in one convenient location.
Benefit Features •
No limit on number of times services may be used during the year.
•
30 day unconditional, money-back satisfaction guarantee - if, for any reason, a member is not satisfied with a purchase at the retail locations or through the mail, the merchandise may be returned within 30 days for a full refund or exchange.
•
Low price guarantee on eyeglasses- if a member finds a lower price anywhere else on the exact same complete pair of prescription eyeglasses purchased at a participating location within 30 days of purchase, the difference will be refunded.
•
24-hour phone and Internet search for locating a
Cost Reductions on:
Eyeglasses 20% to 60% savings on eyewear Contacts 10% to 20% savings at participating locations Eye Exams 10% to 30% savings on exams Surgical Procedures 40% to 50% savings on LASIK surgery
participating retail provider.
Provider Network Our network of 12,000 providers is the most comprehensive in the United States and includes: • Ophthalmologists • Optometrists • Independent optical centers • Regional chains • Department store optical centers (Sears Optical, Target Optical, JCPenney Optical) • National chain locations (Pearle Vision, LensCrafters)
For more information on our Vision Network please contact us at +1 305 760-8739 or visit PayerFusion.com
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
House Calls House calls allow patients who can’t or do not wish to travel to a doctor’s office to access high quality medical care in their homes, hotel rooms or offices. Whatever time of day you need them, our doctors will come to your patients. You can even schedule a non-emergency appointment at their convenience. Our doctors are highly clinically credentialed. They also meet our standards for delivering patient-centered care. Patients receive thorough, unhurried exams from board certified physicians.
Features Comprehensive Treatment • Patient education & engagement • Etiology of disease • Treatment options and rationale • Medication side effects & management • Importance of adherence
In-Home Diagnostics • Full spectrum labs • Rapid response testing • EKG/Pulse oximetry • Mobile ultrasound • Mobile digital x-ray
Assessment • Risk assessment & management • Nutritional • Social service • Home care • Physical therapy • Wound care • Treatment plan compliance
Referral diagnosis include • CHF • COPD • CAD/PAD • Asthma • Diabetes • Alzheimer’s • Pneumonia • Hypertension
Excellent service option for: • High risk for readmission based on morbidities • History of extended hospital stay • History of frequent ER utilization • Discharge with open wound • Coumadin therapy • Discharge with complex medication regimen • Poor adherence with medical and pharmacological therapy • Any mental impairment functional decline • Poor nutritional status • Difficult to control labile diabetes, hypertension, etc.... • Travelers to the U.S. who don’t require ER care
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Continuum of Care
Fee schedules for housecalls are determined by the complexity/severity of the case: Low Severity •
Problem foused history
•
Problem focused examination
•
Straightforward medical decision making
Moderate Severity •
Expanded problem foused history
•
Expanded problem focused examination
•
Medical decision making of low complexity
Valuable information is often lost when patients visit a doctor outside their existing provider group. House Call doctors ensure their care information is preserved and constantly report patient updates to the continuum of care. Since the most up-todate information is always available, a case manager can get the information that they need in real time to guide patients’ treatment plans. Instant reports are provided via electronic health record (EHR) and can be reached over the internet or telephone. In only 48 hours, medical records can be accessed by the patient’s primary care physician or insurance company.
Case Management Ability No more double testing, wasted medication, or uncoordinated treatments that are often caused by poor information across the continuum of care. Case managers have real-time access to a Patient Profile Snapshot and medical records are updated within 48 hours of episode of care. The Patient Profile includes: • Labs • Diagnostic Exams • Medications • Doctor’s Orders • Claims
Chronic Care Program
•
Detailed history
•
Detailed examination
This program aims to improve daily and long term quality of life for patients with chronic diseases by providing ongoing, consistent medical evaluation and treatment at home. Treating doctors educate patients emphasizing complex disease management, risk factor mitigation, wellness and prevention.
•
Medical decision making of moderate complexity
High Readmission Risk Program
Complex/High Severity
Home doctors help high-risk patients avoid hospital readmission. Their focus is on the critical time following patient discharge. The goal is ensuring a continuum of patient medical care during the transition period between hospital discharge and returning to their doctor for follow up care.
For more information on our House Call Program please contact us at +1 305 760-8739 or visit PayerFusion.com 5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Transplant Services Helping navigate the cost and complexities of organ transplant Organ transplants are among the most costly and complex procedures a member may require. PayerFusion provides transplant services to guide payers and members through the entire continuum of care in making well informed decisions and keeping costs under control. Transplants are provided in rate arrangements based on case type. PayerFusion works with both contracted and one-time contract packages if the provider is not in our directly contracted network at the time the services are rendered. Our success rate in contracting exceeds 96%, and our savings average is in excess of a 45% reduction. Our case rates are similar in structure to the US government’s Diagnosis Rate Group (DRG) reimbursement system. When a completed Notice of Potential Transplant (NPT) form is received, we can then share the specifics of our contracted agreement. Contract terms will be outlined in a Contract Rate Summary (CRS). When PayerFusion receives a referral for transplant, it will communicate a Memorandum of Understanding (MOU) to the client confirming the referral and their commitment to pay for the service. An MOU must be signed and returned to legally execute the terms outlined in the CRS. PayerFusion Corporation case rate agreements have five major components: pretransplant discount, fixed procedural rate, “lesser-of� provisions, outlier provisions, and post-transplant discounts.
Fixed Procedural Rate There is a fixed procedural rate for each credentialed transplant program featured in our outcome-based transplant network. The fixed procedural rate varies by transplant type and facility. The typical transplant procedural rate includes hospital charges, professional fees, and organ & bone marrow acquisition charges. Organ acquisition charges are most often included in the case rate. Some facilities merely pass through the organ fees at cost, in which case the case rate would be reduced by $20,000 $40,000, depending on the organ type. Bone marrow search fees are variable and are billed separately.
Our success rate in contracting exceeds 96% and our savings average is in excess of a 45% reduction.
Pre-transplant Discount Contractual discounts are available for pre-transplant services in the form of a percentage off charges. The percentage reduction varies by facility and can be as much as 55% off of hospital inpatient, outpatient and professional billed charges.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
(Fixed Procedural Rate continued) In most contracts, a re-transplant during the same hospital admission or within ten days post-discharge will pay an additional 60% of the initial hospital fee, plus a second organ charge and professional fee. If the patient dies during the transplant, admission is typically paid at the lesser of billed charges or the contracted rate. The case rate most often includes all charges related to the transplant for a stated period of time should a transplant recipient remain hospitalized. If there is an exception, you will be notified and the case rate will be adjusted as appropriate. To the right are some guidelines which were valid as of the date this guide was created.
“Lesser-of” Provisions For more information on our Transplant Services please contact us at +1 305 7608739 or visit PayerFusion.com
“Lesser-of” provisions have been negotiated into nearly all contracts with PayFuseNet providers, which is a significant benefit for our clients. You will agree to pay the “lesser-of” some percentage of billed charges or the fixed rate, whichever is less. We call these modified risk contracts because now you have the full benefit of capitation without the risk of paying more than billed charges.
Outlier Provisions Most of the outlier provisions in our network are flat per diems, but some may have maximum achievable discounts. There will most often be a Med/Surg and ICU/CCU per diem presented. The rates vary by institution, but range from $1,400 -$5,600 per day. Should the patient remain hospitalized beyond the stated number of case rate days, the outlier provisions are then activated.
Post-transplant Discounts Contractual discounts are available for services delivered after the transplant and are usually a percentage of charges. The percentage reduction varies by facility and can be as much as 50% off of the hospital and professional billed charges. Most contracts offer a per diem rate for in-patient hospital care.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Medical Escort Service Medical escort services are a cost-effective alternative to expensive air ambulance transportation for patients who need medical transportation from hospitals after surgeries, accidents, and certain illnesses. For patients fit enough to travel on commercial airlines, medical escort services greatly enhance patient comfort during travel. Why choose Medical Escort Services? • Compassionate, expert care - Medical Escorts deliver care with compassion to give patients peace of mind and ensure that they receive the highest level of medical assistance while making traveling in their condition as easy as possible. • One-on-one service and monitoring - Medical Escorts ensure patients receive attentive service throughout their travel according to their medical needs. This care can include medication administration. Patient’s status and vital signs are closely monitored throughout travel. • Mobility assistance – Patients receive mobility assistance to ensure a hassle-free experience as they maneuver around the airline terminal via wheelchair, handling luggage, flight checkin, security check points and any other travel matters that may arise. • Cost savings - Assistance of a medical escort during travel can often eliminate the need for more expensive forms of medical transportation, e.g. air ambulances.
Excellent service option for: • • • • • • • • • • •
High risk for readmission based on morbidities. History of extended hospital stay. History of frequent ER utilization. Discharge with open wound. Coumadin therapy. Discharge with complex medication regimen. Poor adherence with medical and pharmacological therapy. Any mental impairment functional decline. Poor nutritional status. Difficult to control labile diabetes, hypertension, etc.... Travelers to the U.S. who don’t require ER care.
• Credentialed staff - Escorts are U.S. registered nurses that carry U.S. passports and any necessary visas. Physician escorts can also be arranged for those patients who require more advanced medical care during their travel. • Experience - Specially trained advance care medical staff has extensive experience in air medical escorting and has skillfully, and successfully completed numerous trips, offering patients a comfortable, safe, and worry-free travel experience.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Where can Medical Escorts travel and how does the process work? Medical escorts serve patient needs around the world through use of established commercial airline networks, enabling our trained medical escorts to provide patients with door-to-door service. Patient comfort and safety is our priority. Patients travel with their medical escort in first-class seating, and the escort serves as the patient’s personal concierge during travel. FAA and airline approved oxygen concentrators are carried to accommodate patients who may require oxygen during travel. Patients are accompanied by their medical escort from the pickup location (hospital, hotel, or home) to their drop-off location anywhere in the world. Pick-ups and drop-offs will have prearranged ground transport (limo car service or ambulance).
What is the cost? Our service and pricing is customized to your needs. Fees are case-dependent and vary according to distance of pick-up and drop-off and do not include airfare and Medical Escort travel expenses, which are billed at cost.
For more information on our Escort Medical Service please contact us at +1 305 760 8739 or visit PayerFusion.com.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Personal Health Records, Second Medical Opinions & e-Consultations PayerFusion is proud to offer its clients and group members an integrated package of Electronic Personal Health Records, Second Medical Opinions, and E-Consulation services. Empower Your Members to Take Control of their Health PayerFusion’s PHR & telehealth add-on services are ideal for employers or individuals seeking more control over their medical information and want to contain costs associated with accessing care across the world. PayerFusion can integrate this program with existing services such as Case Management & Disease Management.
Electronic Personal Health Records (PHRs) with Medical Record Recovery
Through an online platform or mobile app, individuals can store and manage all of their medical information in a secure and encrypted location. Members can upload test results, biometric readings, x-rays, and doctor’s notes to their PHR directly, or connect their PHR to their providers office using an interoperable EHR or EMR. For expats and individuals moving abroad, we can provide medical record assistance in collecting information from past providers.
E-Consultations
Our e-Consultations provide a “virtual clinic” visit with physicians over the Internet via webcam on a secure, encrypted platform. Members are granted access to: • • • •
Online fast & simple scheduling Face-to-face consultation with video capability Reports with diagnosis and recommended treatment Improved interaction with physicians and a more empowered, “connected” consumer, reducing ER visits and unnecesary treatment
Why Telehealth? Educate members with access to their online personal health records. Engage members with forwardthinking mobile health solutions . Empower members to take control of their health destiny to save time, money and even lives. Minimizes the risk of medical mistakes, unnecessary tests and procedures. Lowers health related expenses. Reduces absenteeism and time loss from doctor’s visits.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Our Personal Health Records & Telehealth Services are available under a per member per month fee schedule. Plans Include: •
Personal Health Records Platform
•
Medical Records Assistance Program (MRA)
•
Access to Discounted Prescription Drug Program
•
Second Medical Opinions in 48 hours (charged per service)
•
e-Consultations (charged per service)
Second Medical Opinions When faced with a diagnosis of a complex medical problem, PayerFusion offers the comfort of a Second Medical Opinion from a recognized medical specialist via a robust network of providers. A second opinion can help give patients peace of mind in following a prescribed course of treatment in the event of a serious or complex diagnosis. Group members can access over 2,000 different specialists to request a second medical opinion within 48 hours. Coupled with the individuals PHR, specialists have immediate access to your health records making it easy and fast to get a second or third opinion on the go. For those members who want or need an in-person consultation with an expert doctor who is providing a second opinion, PayerFusion can provide additional assistance to arrange for medical appointments, organizing admission to hospitals, making travel arrangements and lodging accommodations.
For more information on our personal health records or telehealth services please contact us at +1 305 760 8739 or visit PayerFusion.com
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
PayFuseNet White Glove Service Our PayFuseNet White Glove Service gives our clients a strong market differentiator and service to offer to a variety of patients with specific demands. This VIP service helps give peace of mind to patients and their families recieving care under stressful circumstances.
Whether a patient needs assistance with a prescription or simply locating a medical facility and arranging easily accessible care, we are there to help. Our PayFuseNet White Glove service helps to provide a healthcare experience that eliminates the hassles, inconveniences and insecurities associated with a variety of medical procedures. Our team is there to guide patients through the admissions process, assist with the understanding of their medical billing process, monitor the patient’s progress – whatever they need, we take care of it. This coordination of logistics and medical care results in an exceptional patient experience.
For more information on our PayFuseNet White Glove Service please contact us toll free at +1 866 752-8881 or via email at info@payerfusion.com.
Service Levels: •
Locating PayFuseNet participiting MDs, Hospitals, and other provider facilities.
•
Scheduling medical appointments and procedures at an approved PayFuseNet provider.
•
Personalized PayFuseNet welcome package including ID card prior to procedure.
•
24/7 support via phone, text, or email - available in multiple languages.
•
Transportation services offered at an additional cost.
•
Assigned Account Service Manager responsible for facilitating all patient care and post-care procedures.
•
Our team ensures that the facility does not bill the patient directly and helps administer all billing procedures.
•
Coordinates any follow-up visits, obtain medical notes, and facilitates whatever else the patient and family requests to enhance their stay and treatment experience.
•
Client branding for providers to reflect unique services and special target customers.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Case Management Our case management services are offered as an integral part of our full-service cost containment model, taking a proactive approach to cost containment.
Our Approach to Case Management At PayerFusion, we actively follow medical cases, monitoring progress to ensure that the patient receives the right care according to the practice of evidence based medicine and best practice guidelines. We coordinate care, evaluate and advocate for options and services to meet a patient’s comprehensive health needs. We actively and frequently communicate with all parties involved to facilitate informed decision-making. Our goal is simple - to promote quality, cost-effective outcomes. By overseeing an entire episode of care, we foresee and prepare for a range of billing situations, doing our part to ensure that payers, providers, and patients alike receive timely service. Through effective case management, we reduce billing errors for payers and facilitate prompt payment to the provider. At PayerFusion, case management not only informs and monitors the patient, but also fuses the gap between payers and providers ensuring a hassle-free reimbursement process.
Success Story A 68 year-old male patient sought treatment at a Center of Excellence in New York for a hip fracture. The underlying cause of the fracture was identified as multiple myeloma. The patient also suffered from COPD. The combination of co-morbidities was life-threatening and required rapid assessment and coordinated, simultaneous treatment. PayerFusion arranged for an oncologist to treat the gentleman while he was receiving orthopedic care. Our case managers worked proactively, communicating closely with the treating facility that assisted in ensuring the correct level of care for the appropriate period of time. We assisted in getting him the right treatment for his COPD and his physical therapy in an outpatient setting which improved his recovery from the fracture and greatly reduced cost. By carefully managing services rendered and paying proactively, we achieved a 70% reduction of expected costs ($290,000 to $87,000) and reimbursed the providers immediately. If this patient had remained hospitalized throughout treatment for his multiple conditions, his treatment would easily have exceeded $400,000. More importantly, this gentleman is still with us, which would have been unlikely if he hadn’t received life saving simultaneous, coordinated and multispecialty care. 5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Success Story
Who is involved in managing your cases?
Through the Internet, patients frequently and incorrectly autodiagnose themselves, seeking the wrong treatment while unknowingly causing unnecessary expense and delay in getting proper care. PayerFusion’s case management department performs “phone triage” or assessment of the patient’s medical situation to prevent this scenario. A 22 year-old male patient suffering from severe lower back pain advised his insurer that after researching his symptoms on the Internet, he was going to the emergency room to seek services from a neurosurgeon. If the patient went to the ER in a U.S. hospital setting as he originally intended, he would have undergone a comprehensive routine work-up to rule out potential conditions. This work-up would have easily exceeded $10,000. Worse, it would have delayed his treatment, prolonging the man’s pain and subjecting him to what in this case would have been unnecessary tests. An internist from PayerFusion contacted the patient, assessed his symptoms and medical history and re-directed him to a same-day appointment with an orthopedic spine specialist as an outpatient. We also schedule a same-day MRI at a freestanding facility. The total cost was under $1,000, the young man was not kept waiting at the ER, and his pain was effectively treated the same day.
PayerFusion’s Case Managers are medically trained personnel (doctors and nurses) that are also experienced in dealing with administrative and financial best practices. They ensure that the right amount of intensity and urgency are given to each medical case and to each patient receiving treatment. In managing a case, we involve all the relevant parties with a stake in the patient’s outcome, including payers, the patient, family members, and the case manager. When warranted, we coordinate with other case managers that may be assigned by a payer and/or a provider, ensuring that each stakeholder has up-to-date information as we seek to drive efficiency throughout the continuum of care.
Why is case management important? The US healthcare system is widely recognized to be the most expensive in the world. A number of factors continue to drive up the cost of care in the U.S., including $700 billion healthcare dollars are wasted each year, according to Reuters. These dollars, instead of improving health outcomes by providing better care, pay for more care (i.e. unnecessary tests and days spent in the hospital). Case management directly reduces this waste. It improves patient outcomes, reducing costs for each patient’s care, and identifies the system inefficiencies that, as corrected, help to reduce future costs for all patients. Below, you can see how the $700 Billion in annual waste is misspent.
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
Our Service Menu Our services are dedicated to assisting international payers using a combination of HIPAA compliant technologies, claims management services and our proprietary provider network. Claims Management • Repricing • Policy Management • Electronic Payment & Claims • Multi-currency Claims Ajudication • Episode Life Cycle Management • Clinical Protocol Management • Member Communication & Service • Utilization Management • Prospective, Retrospective and Concurrent Review
Reporting & Informatics • Data Analysis • Plan Modelling and Forecasting • Benefit & Wellness Reporting • Region and Industry Benchmarks • Reinsurance Stop-loss Disclosure • Benefit Changes Impact Analysis (to employer, member plan) • Normative and Shock Claim Summary Analysis • IBNR Reporting Capabilities • Benchmark Analyses
Case Management • Treatment and Care Facilitation • Evaluation and Recommendation of Care • Follow-up and Reporting • Minimization of Future Complications Through Health Management
PayFuseNet - Our Provider Network • Radiology Network • Oncology Network • Private Label Online Provider Search • Supplementary Networks • Pharmacy Networks • Dental Network • Vision Network • House Call Provider Network • Speciality/Carved Out Networks • National Transplant Network
Policy/Provider Management • Authorization • Eligibility Verification • Treatment Options • Policy Premium Management • Member Enrollment (Electronic & Manual) • Broker Portal with Commission and Performance Indicators
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.
Systems Overview PayerFusion offers a variety of services to assist payers and providers effectively manage patient claims and contain costs. By utilizing a number of specific claims management tools, we can ensure that each claim is thoroughly assessed and priced under the supervision of an experienced team of claims settlement specialists. Please find a list of our operating systems and procedures below: • • • • • • • • • • • • • • • • •
Comprehensive Medical Reimbursement module/capabilities Document imaging system Patient Portal/ Provider Portal Medical Review and Claims Appeal Capabilities (Claims Contestation Processes) Reimbursement Modules
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Member/Dependent Eligibility Checking Multiple Plan Coverage Caps & Limitations CPT/HCPCS structure and Special Provider Pricing – Medicare, Medicaid, DRG, bundled payments Procedure Grouping Coordination of Benefits, Co-Pays & Deductibles Scanning & Image Management Capabilities Claims Processing Including Ability to Scan, Receive via EDI or Manual Entry Capability to Process Claims Through PPO Router System For Electronic Re-pricing Document Image Management System Eliminating Need to Store Paper Claim Forms Easy Retrieval Process Including Ability to Reprint Claim Form
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Check & EOB printing Voucher Printing Including Explanation of Claim Denial Positive Pay & Direct Deposit Capabilities Comprehensive Claims History Display Reports including Claims Paid by Provider, CPT, Procedure and beyond Surcharge & Assessment Check Printing & Reporting Adjuster Analysis Reporting 1099’s & IRS Magnetic Media Filing Web Inquiry Capabilities Check Reconciliation System Including Ability To Post Cleared Checks From Bank Totally HIPAA Compliant
5200 Blue Lagoon Dr Suite 100 Miami, FL 33126 USA
+1 305 760 8739 payerfusion.com info@payerfusion.com
We “fuse� the gap between providers who deserve fair compensation for quality care, payers who seek to pay fair prices for medical services and patients who want the best hassle free care possible.