You're hearing a lot right now about partnerships being formed and interfaces being established to help benefits administrators more efficiently handle the re-pricing of PPO claims. What do you need to look for and what should you expect from a re-pricing solution?

Typically, the service offering promotes the electronic exchange of claims from the administrator to a PPO Network or management firm to automate the external pricing of in-network and out-of-network claims. Some solutions may incorporate edits to the core administration system to further enhance automation levels by checking for complete claim information and potential coding errors before the claim is forwarded for re-pricing.

Here are some considerations to keep in mind:

• The solution is only of value if your contracted PPO networks are connected. Ask to see the list of participating PPOs up-front - if your networks aren't on the list, find out what efforts are being made to recruit their participation. Remember, it could take months or more for the vendor to sign up a new PPO (if at all). The more participating national PPO networks and large regional networks, the better the potential value to your organization.
• Does the service integrate with your existing claims administration system? If not, research what it will take to build an interface. The vendor may or may not absorb this cost. How long will it take to complete the project? Have they connected to your system before? Is integration real-time or batch-oriented? Allow extra time for testing and to work out any "kinks".
• Will your claims be sent directly to the PPO network or management firm keeping the most current contract pricing? If claims go to a third party for re-pricing and their contract data is not the most current, then you could get more errors than you anticipate.
• To facilitate automation, your core system needs the ability to sort and select PPO claims for intelligent routing to the appropriate PPO, and automatic forwarding to an Out-of-Network Negotiator, if appropriate, will further enhance the service's ability to save you time and money.
• How long has the service been in operation? If this is a fairly new or start-up offering, you should understand that it could take some time to get all of the necessary interfaces and routing commands to work smoothly. Expect some delays before you get the results you're looking for.
• What type of turnaround should you expect? That depends on the setups you have established in your system, as well as the vendor's software and connectivity links. At best, you will see turnaround of 24 hours or less, at worst 3-5 days or longer. While these times are much faster than typical manual submissions, the best turnaround times will net you the fastest return on your investment.