International Services

Why is payment integrity so important for people traveling into the United States?

  • The cost for services (medical inflation) rises every year between 12 – 20% in the US.
  • Providers in the US “cost shift” to foreign payors.
  • Existing network discounts are typically applied as a discount off “gross billed charges.”
  • Policing billing practices from provider “partners” within your network can strain those relationships.
  • Typically PPO networks cannot effectively “clean-up” medical bills for errors and validate for accuracy.
  • People who are not used to accessing the US healthcare system can find it very complex and if not assisted properly, their healthcare cost can become extremely inflated.

That is where Equian comes in – we deliver the lowest possible cost of care for inbound US visitors and expatriates, insurance carriers, third-party administrators, self-administered employers, government and travel organizations, and student groups that result in maximum healthcare cost savings. 

Equian analyzes over $33 billion in healthcare charges and realizes savings of $630 million annually.

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Payment Integrity Solutions

Education

Equian can white label our pamphlet of US Healthcare Information and Quick Facts to know before engaging in the system to ensure the covered members understand how to get the highest quality care at the lowest possible cost in the US.

URAC Accredited Medical Management Solutions

Equian offers a Full Suite of Integrated Pre-certification, Concurrent Review, Retrospective Review, and Large Case Management Services.

UM

  • Precertification – Equian drives alternative care and denies inappropriate care. Based on our in-depth understanding of inbound US healthcare programs, pre-existing condition screening is also woven into our precertification process. If the condition is found to be pre-existing, the member and providers are notified of the possibility of claim payment denial. We can adjust the list based on client desire or historical claims data. Selection of services to be precertified can be made on a Plan-by-Plan basis.
  •  We use precertification as the key indicator for early intervention, to ensure potentially high dollar cases will not “slip through” to be first identified only when a claim is submitted.precert
  • Concurrent Review – For inpatient stays, and outpatients services that are re-current, we certify an initial number of days and monitor the patient’s condition, treatment plan and any other factors that may affect the length of stay. We follow the case to discharge and certify days only as medically necessary.
  • Retrospective Review – Equian’s retrospective review process is very similar to an initial certification, with only a few differences in those areas we analyze for savings due to the review occurring after the service has been delivered (i.e. PPO direction is not possible).
  • Large Case ManagementEquian provides a list of conditions and diagnoses that often develop into large claims which is integrated into a case management system, so when precertification is entered, the diagnosis and procedure codes are systematically compared to the list for potential large dollar claims. When the list is triggered, the system prompts a case management screening by an experience Case Manager who reviews the case information to determine if case management would be of benefit. If so, a case is initiated. The Case Manager becomes a liaison between the patient, providers and payor; as patient advocate; perform ongoing case management to ensure maximum use of in network providers, avoidance of duplicate procedures and assurance the most cost effective setting and providers are being used.

High Dollar Medical Bill Audit

During the medical management cycle of services or after a bill is received, cases are flagged for claim audit due to dollar threshold, unusual billings, and percentage distribution of billed charges across categories of services. Those claims are reviewed by claim auditing specialists for accuracy, duplicate items, entry errors, appropriate coding, unbundling and charged amounts. Audit staff work with RN and providers to further determine all charge challenges that can be made.

Assist Services

Equian’s Assist Concierge Service level is a unique service that creates transparency for patients in need of a medical procedure and provides assistance to patients in reviewing the process, setting up inpatient appointments, managing the coordination of the care, and understanding discharge instructions. While cost and quality information is not easily available to members, Equian has several years’ worth of procedure data and costs to supply patients and clients with details as to which local medical facilities can perform the needed procedure in a high quality medical setting while also saving the client significant dollars.

Network Suite

Equian provides a single integrated access point for a variety of network solutions including over 100 national, regional, and specialty PPOs. Our platform eases the administrative burden by eliminating the need for multiple Electronic Data Interfaces (EDI’s), claim format integrations, and changing workflow processes. We offer the most provider coverage in the US and integrate common and standard PPO network processes with all of customized payment integrity solutions detailed above that are focused on international coverage options.

THE US HEALTHCARE SYSTEM

Why do I have difficulty getting a doctor to accept my insurance?

  • US healthcare providers are not required to accept your insurance.
  • One of the first questions you are probably asked when you call to make an appointment with a doctor is – ”Who is your insurance?”
    • If you say only that it is with the government you may encounter difficulty, as most providers have a policy that they do not bill foreign insurance.
    • If you say Equian, this may be of no immediate help either, as Equian is relatively small and not nationally known – the provider will may never have heard of us.
    • You will want to tell the provider that your insurance is Equian, but identify the provider network as well. Please contact our office if you are unaware of the network name.
  • US healthcare providers are accustomed to patients being required to utilize only providers in the insurance network; they may be assuming that if they are not part of your insurance network they will not be paid.

Choosing a physician who will accept your insurance

  • You select any doctor/hospital, however the healthcare provider is not required to accept your insurance.
    • If the doctor does not accept your insurance they will likely expect payment from you at the time of your visit.
      • You will be reimbursed by Equian for this.
  • The best way to ensure a doctor will bill Equian is to use a doctor from our Preferred Provider (PPO) network.
  • What is a PPO?
    • A PPO is a group of hospitals, physicians and other healthcare providers who agree to provide health care services at pre-negotiated rates to plan participants.
      • Healthcare providers join an individual PPO in order to have patients directed to their offices/facilities.
    • Why are PPOs important to you?
  • Healthcare providers a required to accept patients who are part of a PPO they participate with (so long as their practice is accepting new patients); you should not have any problems with the healthcare provider billing Equian directly.

What happens at the doctor’s office/hospital?

  • When you register/sign-in a member of the provider’s staff representative will ask you for your insurance card.
    • If the representative questions the insurance it may be necessary to point out again the name of the provider network.
    • The provider’s representative may call Equian to confirm your coverage and/or obtain coverage details.
  • They may ask you to pay your share of the services, if any.

What if I am required to pay the bill in full?

  • Ask the provider for a bill for your insurance
  • They are aware of what form/information we need
    • The bill will show the patient’s name, diagnosis, date of service, each service(s) provided, and the fee for each service.
  • Send the original of the bill to Equian
  • Make sure the bill is marked that it is paid
    • This can be done by you
  • Equian will mail a check to you
  • Our target turn-a-round time is 8 days

Why do I receive bills?

  • In the US medical bills are ultimately the patient’s responsibility to pay.
    • Insurance is billed as a ”courtesy” to the patient.
  • You may continue to receive a bill until the provider has posted our payment to the account.

What if I need a prescription?

  • You must pay for the prescription and send the prescription receipt to Equian for reimbursement.
  • Pharmacies only send bills to insurance electronically.

Update Address

To update your address with Equian, please click here to fill out a short form.  A representative will handle your request promptly.  Please be sure to fill out the form completely.

Status of a Claim

To check the status of a claim, please click here to fill out a short form.  A representative will handle your request promptly.  Please be sure to fill out the form completely.  You may also call us toll free at (800) 962-6831 during normal business hours.