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 Lack of accurate data and outdated information creates a gauntlet for insurers when building health care networks.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.

Results & Testimonials

TOG’s robust platform is a market leader for network management. The platform’s 24/7 access coupled with their strong contracting experience and processes enabled our health plan’s key decision makers to quickly make strategic decisions (and ultimately have a very successful network expansion)"
Compliance in network management is not an easy feat for any managed care companies, and TOG exceeded our expectations at every front. Their attention to detail, commitment to quality, and robust reporting is second to none in the industry"

Having worked with other provider network vendors in the past, I was skeptical that TOG would be able to provide my organization with what we needed to resolve our adequacy concerns. Any and all concerns were swiftly alleviated within the first round of communication. The TOG Network Team worked collaboratively, communicated clearly and effectively, provided quality provider network leads, and most importantly produced tangible results that bolstered our provider network strength. TOG clearly has the necessary industry knowledge, relationships, and technical skills to help build a provider network needs to offer adequate care for our members."
Thanks for delivering on TN network build in a short time frame and delivering the best network in the state. Being under budget and on schedule is something few companies do well and TOG delivered! Many thanks to you and your team for an outstanding job!"

Our team has been extremely pleased with the level of knowledge and skill that TOG operates with. They exceeded our expectations in transitioning us from our legacy rental network to a more efficient and productive direct contracted network. We were pleased with their professionalism and reliability each step of the way. We highly recommend TOG Network Solutions to anyone seeking provider network and contracting."

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