Overview

PayerFusion is dedicated to assisting healthcare payers by providing effective cost containment, claims management and administrative solutions.
We Are:
Experts in reimbursement guidelines, coding standards, network development and payment Thought Leaders providing clients with guidance and forward thinking approaches to structuring policy and claims models for non-USA companies and domestic self-funded employers Innovators advising clients on best practices for preserving premium ratios and competitive advantage.

Overview

We are a client-focused organization structured to quickly respond to client business requirements and support the highest level of accountability and transparency.
Our Mission:
Achieve maximum reductions and discounts on billed charges by utilizing proactive solutions and fully compliant services Streamline the policy administration process and reduce client administrative expenditures

Provide superior customer service to all stakeholders

Maintain a technological edge through service delivery

Solutions Our solutions are fully customizable to meet the needs of our clients as they adapt to the changes of the US healthcare industry. We Utilize:
Proprietary Provider Network with a zero-balance billing guarantee Technology Solutions to facilitate efficient & accurate claims administration as well as transparency and access to information. Cost-Plus Methodology that bases reimbursements on the actual cost of services- not on an inflated retail price. Forward-thinking approach that connects our knowledge and vision for the future of healthcare into proactive policies and procedures. Total Quality Management & Six Sigma Structure

Services

Claims Management - Both efficient and accurate, our claims management services generate savings while reducing administrative burden.
Cost Plus Claims Reduction Network Affiliates Claim Analysis and Validation Fraud Detection Benefits Verification and Coordination Claims Processing & Provider Payment

Secured/Firewall Environment
Customized Batch Processing Zero Balance Confirmation Customized Explanation of Benefits to payer, client & member

Services

Medical Case Management - Utilizing evidence based

medicine, we ensure that patients receive the appropriate medical care while maximizing opportunities for cost savings.
Coordination of referrals Directing patients to cost-effective providers and facilities Pre-authorizations of medical treatment Coordination of hospital admissions and appointments Concurrent monitoring of patient treatment plans Effective communication between all parties

Post-discharge planning and care coordination

Coordination of air ambulance/commercial airline evacuation

Services

Specialty Services- Providing your policy holders with the

highest level of service is a strong differentiator in a competitive marketplace.
Our White Glove Service provides peace of mind, guidance and a hassle free experience to patients seeking medical treatment. Medical Escort Services are a cost-effective alternative to expensive air ambulance transportation for patients who need to travel after surgeries, accidents or certain illnesses. Second Medical Opinion offers access to expert opinions from world renowned doctors at internationally recognized Centers of Excellence.

Services

Technology- Our customizable technology solutions designed

to support your business objectives, boost efficiency and increase your brand presence.
Online Provider Search ready for your logo, corporate colors and other brand attributes. Call-center management technology to support your customer service and business operations.

Web portal for client tracking of claim activity

Mobile app with provider search customized to your brand specifications

Reimbursement Methodology

Cost Plus- Our approach to claims reimbursement creates

significant savings while allowing providers a fair reimbursement based on the actual cost of service.
Each claim is compared to national data reported by state and federal agencies Utilizing this detail we are able to determine the actual cost of service, needs of the provider to offset losses from providing under-funded care, and the fair retail cost of the service provided. Our expertise and experience on all sides of the healthcare industry gives us an invaluable advantage in negotiating effectively and maintaining long-term relationships.

Provider Network Options

PayFuseNet - Our proprietary provider network gives your

members freedom of choice when accessing care while maximizing your savings.
Network presence established across the USA, Puerto Rico, the Caribbean, Latin America, Europe, Asia, New Zealand and South Africa By directly contracting and managing PayFuseNet, we develop strong relationships with providers and attain the most value for our clients Fully compliant with all USA federal and state regulations Zero-balance billing guarantee

Provider Network Options

Affiliate Provider Networks - PayerFusion has partnered with

best-in-class provider networks across the USA enabling us to offer regionalized cost containment solutions
Allows for a more strategic approach to claims pricing and network access by region and provider for maximum discounts A comprehensive solution for filling in network gaps and satisfying claim repricing needs

All medical specialties are covered including neo-natal care, cardiac, serious trauma hospitalization, surgeries and more

The PayerFusion Advantage

We provide superior cost containment that leads to both short and long-term savings by effectively controlling your cost per claim Our fine-tuned services, expertise and experience in healthcare reduces your administrative burden and ensures the smooth administration of your policies Vigilant monitoring and adherence to continuously changing state and federal regulations along with ongoing development of best practices and policies