Are you looking at an In-Network claim and wondering if it is reasonable? Do you want peace of mind that the claim is compliant and fair? If so, you are not alone, and GEMDeal-IN may be the solution that you have been looking for.

How does it work?

We recommend that our clients screen In-Network claims through our GEMScreen product to see if it is a suitable candidate for review. At Global Excel, we do not think that all In-Network claims are problematic – and so this tool helps focus our collective efforts.

In order to further validate if the claim is a good candidate for review, one of our highly trained negotiators with over 10 years’ experience will benchmark the claim against usual and customary databases, Medicare rates, reported costs, provider history, provider quality markers, etc. If we are unconvinced that the claim merits the measure of contacting the provider to consider an alternative rate, we will send it back along with a benchmark report.

However, if the review reveals any coding or clinical deviation it is escalated to our GEMCode or GEM-MD services for further examination. Once the claim is validated and benchmarked, our negotiators call the provider to discuss the situation, an agreement is reached, a document is signed, and you are sent a repricing report so that you can issue the payment in your system. If the provider is unwilling to negotiate we offer other options such as StrataGEM.

GEMDeal-IN is available for any claim type (e.g., Hospital, ASC, Physician, Anesthesiology, Ambulance, Dialysis, Pathology, Implants, etc.).

How long does it take and is there a dollar threshold?

We recommend that our clients consider a 10-day turnaround time so that we are not forced to compromise value for speed. If the provider is unwilling to consider our position, we close it and send it back, or the case is transferred to StrataGEM for further review. This product uses a number of expert resources and is only suitable when specific requirements are met; We pleaseconsult our referral guidelines.

Can I use GEMDeal-IN as the specialized service overlay for higher dollar claims within the pipeline to my primary PPO?

Yes. In fact, that is how many of our clients are set up, and our results outperform any other industry solutions.

How much does it cost?

Our rates are contingent upon our savings – no deal, no cost. Also, since you have already paid for access to the network, our fees are based only on the additional value that we are able to secure for you.

How is your approach to In-Network negotiating any different from other vendors?

Our tools are the best in the industry.We use the finest coding, clinical and financial benchmarks to profile the claim. This best-in-class information is managed by one of our seasoned negotiators. Our negotiators average 10 years of experience and that makes a difference that you will see in the results. We don’t just cut a bill and walk away like most bill review companies, leaving you with noise and liability issues; we work with the provider to reach a mutually acceptable rate agreement.

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