Challenges abound in the health care system. Lack of accurate data and outdated information creates a gauntlet for insurers when building health care networks.
From analysis, strategy, and expansion to provider credentialing, minimizing corrective burdens, and resolving overpayment errors, TOG Network Solutions endeavors to accelerate significant changes in health care delivery across the nation.
TOG offers practical knowledge and a tailored suite of services for health care insurers seeking to build value and improve efficiencies while lowering costs.
Services
Network Analysis & Strategy
Provider Recruiting & Contracting
Provider Data Management
Compliance & Corrective Action Plan Mitigation (CAP)
Payment
Integrity Solutions
Network Analysis & Strategy
From scrutinizing network information to finding the correct resources, TOG Network Solutions uncovers opportunities and designs tactics to grow and optimize health care for insurers.
Provider Recruiting & Contracting
TOG’s expert team of recruiters has the deep knowledge and expansive connections to enroll physicians, hospitals, and ancillary providers into networks.
- Commercial: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organizations (EPO), Point-of-service (POS), High Deductible Health Plans (HDHP).
- Exchange: Small Business Health Options (SHOP) and individual (HMO, PPO, EPO, POS).
- Medicare Advantage: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs).
- Medicaid: Temporary Assistance for Needy Families (TANF); Women, Infants, and Children (WIC); State Children’s Health Insurance Program (S/CHIP); Supplemental Nutrition Assistance Program (SNAP); National School Lunch Program (NSLP).
- Tribal: Indian Health Service (IHS).
- Military: TRICARE, Veterans Health Administration (VHA).
- Behavioral: Adult, Child, and Adolescent, Geriatric, Addiction, including both facilities and professionals (Psychologists, Social Workers, Licensed Professional Counselors, Psychiatric/Mental Health Nurse or Nurse Practitioners).
Provider Data Management
In an industry that must often navigate the pitfalls of maintaining frequently accurate and consistent data, TOG understands the importance of keeping crucial provider information up-to-date through its proprietary data management platform.
Compliance & Corrective Action Plan Mitigation (CAP)
TOG knows that CAPs are costly and time consuming. For over a decade, TOG has worked with companies to develop clear guidelines to both resolve and prevent state and federal compliance actions.
Payment Integrity
Overpayments – analyze paid claims to identify provider errors resulting in overpayments, including:
Data Mining
- Eligibility
- Duplicates
- Contract Compliance (outpatient/inpatient, high-cost drugs, etc.)
- Bulletins & Policies (multiple surgery, bi-laterals, NCCI/p2p/MUE, Status
- B code, global surgery, technical component, etc.)
- Fraud, Waste, and Abuse (overutilization, billing for services not rendered, staff credential level, Rx rebate/vouchers, etc.)
- Contract rate pricing
- Division of financial responsibility (DOFR)
- Co-pays, deductibles, and out-of-pocket maximums
- Member eligibility
- Authorized services
Coordination of benefits and third-party liability
- Pre-pay
- Post-pay
Appeals/Grievances (A/R) – Reserves
Underpayments – analyze paid claims to identify payer errors resulting in underpayments,including:
- Contract Configuration Error
- Provider Configuration/Linkage Error
- Retro/Late Rate loads
- System Errors (claims platform)
- Vendor Errors (payment integrity, ancillary, etc.)
Accurate Payments
Provide datapoints for specific provider education on correct billing policy/procedure when appealed/grieved claim was paid correctly.
Network Analysis & Strategy
From scrutinizing network information to finding the correct resources, TOG Network Solutions uncovers opportunities and designs tactics to grow and optimize health care for insurers.
Provider Recruiting & Contracting
TOG’s expert team of recruiters has the deep knowledge and expansive connections to enroll physicians, hospitals, and ancillary providers into networks.
- Commercial: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organizations (EPO), Point-of-service (POS), High Deductible Health Plans (HDHP).
- Exchange: Small Business Health Options (SHOP) and individual (HMO, PPO, EPO, POS).
- Medicare Advantage: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs).
- Medicaid: Temporary Assistance for Needy Families (TANF); Women, Infants, and Children (WIC); State Children’s Health Insurance Program (S/CHIP); Supplemental Nutrition Assistance Program (SNAP); National School Lunch Program (NSLP).
- Tribal: Indian Health Service (IHS).
- Military: TRICARE, Veterans Health Administration (VHA).
- Behavioral: Adult, Child, and Adolescent, Geriatric, Addiction, including both facilities and professionals (Psychologists, Social Workers, Licensed Professional Counselors, Psychiatric/Mental Health Nurse or Nurse Practitioners).
Provider Data Management
In an industry that must often navigate the pitfalls of maintaining frequently accurate and consistent data, TOG understands the importance of keeping crucial provider information up-to-date through its proprietary data management platform.
Compliance & Corrective Action Plan Mitigation (CAP)
TOG knows that CAPs are costly and time consuming. For over a decade, TOG has worked with companies to develop clear guidelines to both resolve and prevent state and federal compliance actions.
Payment Integrity
Overpayments – analyze paid claims to identify provider errors resulting in overpayments, including:
Data Mining
- Eligibility
- Duplicates
- Contract Compliance (outpatient/inpatient, high-cost drugs, etc.)
- Bulletins & Policies (multiple surgery, bi-laterals, NCCI/p2p/MUE, Status
- B code, global surgery, technical component, etc.)
- Fraud, Waste, and Abuse (overutilization, billing for services not rendered, staff credential level, Rx rebate/vouchers, etc.)
- Contract rate pricing
- Division of financial responsibility (DOFR)
- Co-pays, deductibles, and out-of-pocket maximums
- Member eligibility
- Authorized services
Coordination of benefits and third-party liability
- Pre-pay
- Post-pay
Appeals/Grievances (A/R) – Reserves
Underpayments – analyze paid claims to identify payer errors resulting in underpayments,including:
- Contract Configuration Error
- Provider Configuration/Linkage Error
- Retro/Late Rate loads
- System Errors (claims platform)
- Vendor Errors (payment integrity, ancillary, etc.)
Accurate Payments
Provide datapoints for specific provider education on correct billing policy/procedure when appealed/grieved claim was paid correctly.