COST OF CARE

Our Medical Strategies are designed to navigate the Patient Journey from Directional Care to Care Insights to Cost of Care.  And it’s our mission to help people get to the Right Place at the Right Time for the Right Care at the Right Cost to ensure our clients’ needs are addressed throughout each step of the journey. Our Cost of Care Strategies are designed to ensure patients, payers and providers agree on the Right Cost for medical care.

In-house Fee Negotiation

Opus MedStrategies has an in-house team of more than 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 less noise.

Opus offers three levels of negotiation support. Our first line negotiators support a highly automated process for lower dollar claims. Our second level of negotiation support focuses on inpatient and outpatient claims. Opus’ Complex Claims Unit (CCU) composes our third level of support. The CCU brings together a roundtable team of financial, legal and clinical professionals who conduct forensic reviews of  complex, high-dollar claims and performs a savings study to determine the optimal approach to pay fair market rates.

Our customized negotiation strategy combines software automation, 3 levels of in-house professional expertise and proven processes to deliver negotiations on any size claim.

Bill Review

Opus delivers extensive bill review services to ensure that medical claims are correctly billed by the provider. Our in-house financial and clinical experts deliver a holistic report that validates the merits of the claim and reimbursement amounts by forensic examination of the claim.  We utilize industry benchmarks to establish real costs and inspect medical necessity of the care rendered. Opus is also well-equipped to negotiate claims for savings after the bill review report is generated.

Complex Claims Unit

Opus’ Complex Claims Unit (CCU) is composed of certified coding experts, Registered Nurses and Physicians, in-house legal counsel and seasoned negotiators who examine challenging claims in round-table sessions to determine the optimal approach. Our CCU team then establishes fair market rates and negotiates a secured financial settlement with signed releases from the provider.

Our highly specialized CCU team examines financial, legal and clinical issues surrounding each complex claim.

CCU experts utilize multiple reimbursement benchmarks and a detailed record review to deliver a wholistic view and savings study to determine the optimal approach to pay fair market rates. We take the lead in securing all documentation. After our CCU reviews the complex claim, we deliver guaranteed savings through provider sign-off for every qualified claim.

Reference-Based Pricing

Medicare & UCR Repricing Services
Plans and Payers in need of a repricing services can partner with Opus to access Medicare and UCR claims repricing.

Opus 360 Out-of-Network Repricing
Plans and Payers seeking strategies outside of traditional PPO out-of-network services can access Opus 360. Our customized solution is driven by data and provider experience for a cost-based benchmarking program. Opus 360 blends bill review, fee negotiation, PPO and direct contracts and Reference-Based Pricing to achieve results while maintaining a high level of client service to pre-defined client targets with limited balance billing.

We provide Reference-Based Pricing services for repricing, Opus 360 out-of-network repricing and our FairChexTM Facility Program.

FairChexTM Facility Program
In partnership with a leading Medical Management company, Opus offers a unique facility program for those looking to control inpatient and outpatient claims costs. Our strategy is focused on patient and provider engagement prior to care to secure acceptance of benefits or consider alternative locations for treatment. Utilizing FairChexTM and supported by a physician and ancillary provider network, Plans and Payers can limit reimbursement to a pre-defined threshold, while mitigating balance billing. This program may seamlessly include pre-certification and pre-approval along with case management services to integrate cost containment services. Payers who opt-in to FairChexTM Plus also receive secured negotiations prior to care.

Opus AI

Opus AI is our proprietary claims assessment and routing software that executes a three step Screen, Score, Save process.

Screen
Opus AI first screens claims by adding 100+ customized triggers missed by traditional bill edit solutions. Issues surrounding egregious pricing, drug utilization, never events, quality of care, implants, fraud and legal recovery are identified.

Opus AI incorporates edits, clinical, financial and legal triggers and client thresholds to automatically route claims for the greatest savings.

Score
Based on the screening process, Opus AI] scores each claim on clinical, financial and legal triggers and references client thresholds to determine the next steps for the greatest savings.

Save
The claim’s score determines how our proprietary system automatically routes the claim to the appropriate cost containment solution(s) to maximize savings in alignment with a client’s custom configuration. The savings routing process may include multiple savings strategies.

Opus 360

Most healthcare companies tout client service, but do they truly walk the walk? At Opus MedStrategies, we deliver a client experience like none other with Opus 360.

Opus 360 provides payers a full view of out-of-network healthcare expenses with benchmarks. Our program empowers payers to thoughtfully select reimbursement and appeals targets for out-of-network spending via a savings performance dial.

Opus 360 is designed for collaboration to establish cost-based benchmark targets for medical reimbursements and appeals for a blended approach to out-of-network claims.

A consultative review of claim experience and client thresholds determine the savings dial setting for target reimbursement and appeals rates. Next, our dynamic system leverages years of provider experience to blend bill review, fee negotiation, PPO and direct contracts and Reference-Based Pricing to achieve results while maintaining a high level of client service.

Plans and Payers have complete visibility on the value of the reimbursements and total control to fine-tune reimbursement targets and the composition of cost containment strategies to achieve greater savings.

Value-Based Reporting

When it comes to better utilization of the healthcare system and controlling medical spend, Opus MedStrategies earns its name as a partner that Plans and Payers can rely on to guide them.

Our Value-Based Reporting strategy supports all plan efforts. We benchmark performance using Medicare, UCR and other rates for financial analysis. And we have the tools and data to provide clinical information, as well.

We deliver standardized and custom-built reports and analytics to fully support your sales and retention efforts.