Coalition America, Inc. (CAI) utilizes proprietary technology to deliver significant discounts on healthcare billings. CAI directly services over 200 clients, representing more than 12,000 health plans nationwide, and offers a one-stop solution for discounting medical bills while reducing administrative costs through technology. Clients interface with CAI through HIPAA compliant EDI or the Internet to reprice in-network and out-of-network medical claims.

Carrier Level Cost Containment

CAI has developed leading edge technology to deliver “Carrier Level Cost Containment” services focused on controlling the increase in healthcare spending. Many small and medium sized payors and self-insured employers don’t have the resources to independently access carrier level services for cost containment from multiple sources. CAI has developed a seamless process for integrating best-in-class cost containment services including access to carrier level PPO networks, real-time fraud detection, enhanced claim editing, chronic disease and utilization management, as well as retrospective analysis and interpretation of results for payors. This integrated approach to cost containment has a greater impact on the overall management of benefits costs and will help to control the annual rate of increase in healthcare spending.

Carrier Level Cost Containment includes:

• Prospective review and editing of providers and claims data to identify questionable charges
• Access to Carrier Level PPO Networks
• Streamlined repricing of out-of-network claims
• Retrospective analysis of how benefits are being utilized, who is consuming benefits resources, and how benefit plans can and should be modified to control benefit costs
• Analysis to identify potential fraud, waste and abuse
• Seamless integration through a single connection point
• Demonstrated savings and ROI

Real-Time Fraud Detection – Questionable Provider File (QPF) Access

Provided through a partnership with Lodestone Solutions, LLC is a healthcare centric database company integrating demographics, validation information, and quality characteristics across extensive profession types and areas of practice. The company compares and matches data from various disparate data sources to identify the most accurate depiction of the individual provider and group practice. In addition to providing data content, the company provides a family of data services including database cleansing, deduplication, hygiene, address normalization, geo-coding, etc.

• Single portal for information from over 600 official sources
• Real-time provider checking
• Provider master file scrubbing

Enhanced Claim Editing – Clinical & Coding Edit Services

Provided through a partnership with Bloodhound, Inc. provides claims editing and business analytics services to all participants in the claims revenue cycle. Its services, technologies and products combine to offer any payor of claims the most comprehensive solution to preventing overpayment or miscoding of claims. Delivered as an ASP application, Bloodhound’s premier service, ClaimsGuard, enables real time edit processing of claims for accuracy including duplicates, up-coding, rebundling, and unbundling of codes. Customers engage Bloodhound to improve their profitability, increase auto-adjudication rates, gain insight into provider/payor historical behavior and assist them in building more efficient claims processes.

• In-network and out-of-network claim review
• EDI batch & real-time editing across patient history
• 16 million open-sourced edits
• Increased auto-adjudication rates
• Prevents overpayment & miscoding

Primary PPO Network Management Services

National Travel Network
The Travel Network is a seamless "national network" made up of key PPOs in all 50 states. Traveling employees can access Travel Network providers for in-network benefits when outside their state of residence resulting in greater savings for the client, and lower out-of-pocket costs for employees.

Transplant Savings Program
CAI offers significant savings of 30-50% on all transplant related services through its relationship with a National Transplant Network. The Transplant Savings Program provides experienced case managers who can direct patients to nationwide, high-quality providers and streamlines the process for repricing all transplant related bills.

ProviderNow
Primary PPO provider information can be accessed through the convenience of the Internet, 24 hours a day, and 7 days a week.

Patient Referral Line (PRL)
PRL gives employees quick and easy access to hospitals, specialty facilities and physicians in their Primary PPO via their telephone, as well as fax-on-demand directories.

Out-of-Network Repricing Services

Provided through a partnership with many supplemental PPOs, direct provider contracting efforts, and the proprietary fee schedule development of CAI.

Supplemental PPO Access

• CAI has discounts through over 50,000 proprietary contracts
• PlanCare America direct contract development
• Access to up to 24 supplemental networks per state
• Real-time internet repricing through RepriceNow
• EDI transfer repricing

Provider Negotiation Services

• No minimum dollar threshold for negotiations
• Negotiations grouped by provider to enhance savings
• Prospective negotiation services available
• Client specific turnaround times
• Fewer claims to resend to other vendors

Established Reimbursement Schedule - Provided through a partnership with Navigant Consulting, Inc., a NYSE company, with broad experience in developing fee schedules for large carriers and for federal and state governments.

• ERS calculates reasonable and fair hospital reimbursement on a cost plus basis
• ERS determines reasonable and fair physician reimbursement based on known historical geo-coded payments by CPT
• Call center for provider education to avoid balance billing
• Alternative to percentage off billed charges and UCR

Repricing Technology

Internet - RepriceNow
CAI can provide immediate turnaround for in-network and out-of-network repricing through the Internet using RepriceNow.

Electronic Data Interchange (EDI)
For companies with a high volume of claims to be repriced, CAI can connect with a client electronically to quickly and efficiently transport claims for repricing and back for automated adjudication.

Reporting

Online Claim Tracking
Online claim tracking is a real-time solution offered through this Web site to assist clients in tracking the status of claims sent to CAI for repricing.

Online Activity Reports
Online activity reporting is a real-time solution offered through this Web site to assist clients in viewing their savings activity with CAI.

Workers’ Compensation

CAI has developed a unique program to generate significant savings on workers' compensation medical bills. Our strategy is simple - utilize a three-tiered approach to secure the greatest savings possible.

Customer Service

CAI is your Five Star Support Source!