PPC Partner-Plus Consulting, Inc.
Healthcare Claim Reviews
 

 

Products & Services

PPC's breadth of products and services gives it a significant advantage in its target market. The TPA, consultant, or employer group may look to their partners and outsourced vendors to manage and coordinate the many complex components that make up a comprehensive and efficient self-funded program. PPC has assembled internal and external expertise in virtually every category of standard and advanced review products and services and has expanded traditional thinking into value added service categories that differentiate the client in the marketplace.

We deliver exceptional review services by skillfully combining leading edge technology solutions and industry expertise in healthcare operations in reviewing all facets of the healthcare arena. This includes claims, customer service, utilization review, case management, PBM reviews, and network management. Management believes that it is the value added categories that truly differentiate PPC from other specialized review firms. These categories include traditional claim review, internal claim review, stop-loss, reinsurance, quota share reviews, underwriting reviews, electronic data reviews, utilization case management reviews, acquisition and merger reviews, and operational support reviews.

 

Let us know which of our products and services you are interested in and we will be happy to send you more detailed information. Thank you for your request.

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Healthcare Claim Review Services
PPC provides quality industry reviews for self-funded medical plans, system plan implementation, eligibility, customer service, . . . [more]
network management and re-pricing of claims. Our experience in the marketplace with various claim systems and review of operational processes from small to large national administrators position us with a wealth of information to be utilized for up-to-date reporting and review.
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Outsourced TPA Internal Quality Reviews
PPC provides quality internal claim review services for Third Party Administrators who choose to outsource . . . [more]
their internal quality claim review programs. An outsourced program allows for a third party to substantiate and validate the internal claim operational processes of a company are being met. Claims are selected monthly from each claim office. The claim review program is designed specific to each TPA and includes reviews for performance guarantees producing monthly and year to date reports for management review. An outsourced program brings the expertise of quality reviewers with an objective viewpoint and unbiased recommendations which can be used as a marketing tool to bring the greatest value to the TPA's client base.
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Operational Support Reviews
PPC provides operational review services to healthcare organizations and also partners with the CPA firm . . . [more]
of Dorothea Krempein, CPA, to provide support review services (PPC is the claim service reviewer) including SSAE16 operational reviews. Dorothea Krempein, CPA,  provides SOC 1, SOC 2 and SOC 3 reporting with CPA accreditation and states that SSAE16 operational reviews distinguish your organization from competitors by showing that your system contains third party reviewed control objectives and control activities.
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Utilization Management Reviews
PPC has experienced nurses and medical management personnel available to attend onsite reviews . . . [more]
of a client's utilization programs. Electronic interfaces to the claim system are critical in delivering seamless utilization management services. PPC offers the ability to review the utilization company's processes and their integration into the claim system for ultimate resolution and payment related to utilization management services.
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PPO Networks and Network Management Reviews
PPC leverages its experience in reviewing national and regional PPO organizations across the country . . . [more]
to deliver effective network contract review. PPC has experience in reviewing ambulatory service groupers, DRG groupers, Per Diems, global/case rates, percentage discounts and the various stop loss attachments associated with these types of discounts.
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Stop-Loss/Reinsurance/Quota Share Reviews
PPC performs an operational review of processes and procedures to include a review . . . [more]
of paid claim totals, voids, refunds, claim payments, review of pended claims, verify uncollected overpayments, contract compliance and enrollment verification.
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Pharmacy Benefit Management (PBM) Review
As an increasingly visible and important benefit, PPC can provide a review of PBM vendor partners . . . [more]
for Claim Administrators. PBM's must provide several critical functionalities including (1) interfacing with the client or administrator for eligibility electronically, (2) employing sophisticated programs to control administrative and claim costs, and (3) providing national access. PPC has opportunities through its various types of reviews to stay abreast of the best practice methods in PBM management.
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Underwriting Reviews
PPC will verify the underwriting process with compliance to . . . [more]
underwriting guidelines and review underwriting files to measure performance and outcomes.
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COBRA Administration Reviews
PPC offers review services of COBRA administration . . . [more]
PPC provides a client-specific approach to COBRA administration reviews and can develop a custom review program.
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Premium Accounting Reviews
PPC performs reviews of eligibility and enrollment systems with interface to premium systems . . . [more]
to determine not only the accuracy of data imported and exported to vendors but also accuracy of premium rates applied, collected and disbursed.
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Electronic Edit Reviews
PPC performs reviews to evaluate health plan vendor claims administration performance in specific payment categories . . . [more]
including handling of duplicate claims, payments for excluded services and other areas. Our reviews encompass detailed analyses of standardized claims data sets to identify potential overpayments. The electronic analyses are typically accompanied by an on-site sample review to validate findings, propose corrective actions including system or process changes and identify specific claims for overpayment recovery.
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Overpayment Identification and Recovery
PPC will review plan contracts and policies to identify overpayments through data analysis of claim data. This review can be performed . . . [more]
in conjunction with the healthcare review or as a stand alone recovery review. A third party administrator can maximize their overpayment recovery by allowing PPC to review their plans for potential overpayment recovery. An employer group will benefit through lower cost utilization by the plan when overpayments are accurately tracked and recovered for the plan.
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Acquisitions and Mergers
PPC has experienced management personnel with over twenty years overseeing and managing . . . [more]
large third party administrations. Often a company's internal management is overloaded with internal projects to handle the time consuming due diligence process. Our experience in this area can ease the workload and give an objective review of the strengths and weaknesses of the company under consideration.
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