Cost Management

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We Work Hard to Extend Your Health Care Dollars

In our ongoing efforts to control costs, we have the following options available to help identify and implement useful cost management tactics:


Determination of Out of Network Allowances

As a plan sponsor, you can determine your plan’s out-of-network allowances. This flexibility allows you to set pricing for any claims that occur as a result of participants going outside of your elected provider network. You can use the following industry standard guidelines to help you decide what values will work best for you:

1. Resource-Based Relative Value Scale (RBRVS)
2. Diagnostic Related Group (DRG)
3. Ambulatory Surgical/Surgery Center Schedule (ASC)

You also have the flexibility to elect a percentage of RBRVS set by Medicare.

Coordination of Benefits

We obtain Coordination of Benefits information to prevent mistaken payment of benefits for those with more than one health insurance plan. In this case, one plan will become your primary plan and it will pay your claims first. The second plan pays towards the remaining costs of your claim. We solicit for secondary insurance at open enrollment. Our claims specialists also verify participant records prior to claim payment to ensure the correct benefits are applied.

Medical Care Management

We continuously look for ways to help improve the lives of our participants by regularly researching new technologies and programs that result in overall greater wellbeing. Care management programs, such as wellness and disease management, offer preventive solutions to reduce future health risks. Therefore, we offer several options that can help curb health care spending while providing quality benefits to your workforce. Additionally, programs such as utilization review and case management, are effective cost management options for administering episodic care.

Pinnacle has a specialized team of nurses on standby to assist with any care management situation as it arises. We also provide supplemental care management services in conjunction with any program you choose and assist in determining the most appropriate programs for your group.

Large Case Management

We strive to manage claim dollars to help you contain costs. This is one reason why we believe our care management team is so essential in cost management. Our team works with physicians, patients, and family members to develop the best care plan for patients with substantial medical expenses. In addition, our nursing staff helps coordinate claims processing with vendors and your reinsurance carrier to maximize your plan savings.

Internal & Hospital Claim Audits

Audits are essential to minimize wasteful spending. Therefore, to ensure accurate claims processing and payment precision, we perform random internal audits. Our internal auditing team regularly reviews claims on your behalf.

Through a successful audit, you can be sure claims are paid appropriately by accounting for items that include network discounts, provider payments, and identifying fraudulent activity. This allows you to assess and recoup any unchecked losses and identify areas for improvement. We are also happy to work with an external audit firm on your behalf.

Duplicate Payment Prevention

Our proprietary health benefit management system automatically screens claims to prevent duplicate payment.

Third Party Liability & Subrogation

We identify third party liability claims, such as work-related injuries, accidents, or subrogation claims and assist in recovering monies owed to your plan. Subrogation claims are those that another party is actually responsible to cover damages or losses as a result of an injury or accident. Our system automatically identifies these claims and begins the recovery process.

Utilization Management

The purpose of utilization management is to identify and resolve delivery of care issues that impact resources and patient outcomes. We conduct this type of organizational evaluation to assess the quality, risk, and costs associated with care. By reviewing discharge planning, clinical case appeals, provider certification, and quality of care associated with each facility, we ensure that the least costly, yet most effective treatment is used.

Disease / Health Management

Chronic and serious diseases often require specialized care. Our disease management program provides eligible participants with treatment options to mitigate complications associated with common ailments, such as high cholesterol, high blood pressure, diabetes, and asthma. An effective disease management program addresses symptoms related to these disorders before they become more severe. This important service helps promote healthy living, encourages compliance with medications and doctor visits, and provides an overall benefit to you and your participant.

Wellness Programs

Improving and promoting health and fitness in the workplace is a vital asset. It can also save you money and boost company morale. With a wellness program in place, you have the potential to lower health risks, reduce medical spending and increase workplace productivity while providing employees with rewarding benefits. You can customize programs to offer employee incentives for participation and work in conjunction with our disease management program.

We offer an array of wellness services to help you, your employees, and their dependents make healthy lifestyle choices. Whether your goal is to lose weight, start an exercise plan, quit smoking, or manage stress, you’ll receive the information, motivation and tools you need to get started.

Onsite Employee Clinics

Serving as your company advocate, we provide onsite employee clinics that offer convenience and increase accessibility to care. These clinics are designed to conduct general health assessments, treat common ailments and prescribe relative medications, and can even help identify if specialized care is needed. We staff our onsite clinics with highly trained medical physicians and nurses who deliver personalized, affordable alternatives to traditional hospitals and medical treatment.

Some key benefits include:

  • Ultimate convenience; your employees don’t have to travel 
  • Reduces time away from work
  • Increases likelihood of earlier diagnoses and treatment
  • Reduces the amount of emergency room visits
  • Program flexibility; you can choose from mobile or stationary set-ups

These advantages all work to help lower the cost of health care premiums, while boosting overall employee health and wellbeing.

Custom Plan Designs

One of the primary benefits of self-funding is the high level of flexibility. Our proprietary systems and experienced team can tailor programs and benefits to suit your unique needs and positively impact the lives of your employees. We offer countless plan designs for medical, dental, vision and pharmacy health packages. Taking industry benchmarks into consideration, our account managers stand ready to help you assess the numerous plan variables to help you develop the most cost-efficient strategy for implementation. Because we not only administer but manage your claims data, we can provide recommendations for ways to maximize benefit utilization, providing even greater savings.

Proprietary Networks

Our longstanding relationship with leading provider networks throughout California and Arizona allows our clients take advantage of significant discounts, greater coverage areas, and more provider choice not available through other TPAs. With a commitment to satisfying employers and participants, we can optimize your network to align with your needs.

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