The difference between traditional specialty benefits management and us.


Educational and Collaborative

HealthHelp’s consultative process uses evidence-based criteria to guide providers in ordering the most appropriate tests, procedures and treatments for their members.

The HealthHelp approach brings the ability to recognize, evaluate, and effectively integrate factors such as timeliness, safety, and quality of care into the decision-making process, along with expert guidance through the engagement of an academically affiliated, practicing, and board certified specialist.

Through a value-based approach, HealthHelp ensures that patient care includes:

  • Improved safety and quality of care
  • Reduced inappropriate testing and therapies
  • Delivery of appropriate amount of treatment
  • Optimizing provider practices by ensuring guideline compliance

Leading to an immediate and measurable cost savings

Up to 20% reduction in spend

lasting education and provider ordering optimization

Comprehensive Specialty Benefits Management Programs

For health plans focused on member outcomes, our comprehensive programs help ensure the best treatment outcomes are met every time. We manage all lines of business, including Commercial (Group, Individual, and ASO), Medicaid, and Medicare. Our education and collaboration based model is also an ideal fit for health plans migrating to value-based care by ensuring that providers are following evidence based guidelines and delivering the most appropriate care for your members.


Long-Term Value-Based Outcomes

HealthHelp creates continuing value through:

  • Shifts in provider ordering behaviors through education and collaboration
  • Reducing the risk of future complications and improving member outcomes
  • Reducing radiation exposure for members
  • Ongoing physician collaboration and education
  • Guiding the physicians with best practices through the spectrum of health plan services
  • Conducting outcomes research to show safety and quality improvements
  • Becoming a trusted partner for the payers by delivering higher quality and lower cost
  • Creating competitive advantage in the market place through a positive provider experience
  • Change agent for health plans to transform from a transactional model towards an end-to-end solution

VBC Supporting the Transition to Value Based Care


We can achieve

A better healthcare experience using a collaborative approach and advanced technology.

Evidence-Based Practice

HealthHelp’s clinical guidelines are developed from collaborative efforts between practicing clinicians and renowned academic centers. Following a formal and unbiased process for evaluating peer-reviewed literature and general practice recommendations, our evidence-based guidelines are designed to optimize member outcomes.

Dynamic Program Design

HealthHelp’s Consult platform includes a dynamic program design that visually and seamlessly modifies or captures new practice guidelines and protocols. This provides our medical directors direct control over the best practices utilized within each specialty and the ability to update guidelines in real time based on the latest published peer-reviewed literature.

Educational Behavior Reform

By supporting and educating providers about safety, quality, and appropriateness of tests and treatments for each specialty under management, HealthHelp drives voluntary compliance and alters patterns in procedure requests. These behavior changes eliminate unnecessary utilization and increase savings.

Automated Decision Support

Our web-based Consult system and clinical decision support tools allow providers to seamlessly receive guidance for performing the most appropriate tests and procedures, based on the relevant member clinical criteria. Providers are guided to the best alternatives to the original test or procedure request. If the initial request is unable to be resolved, further clinical review and guidance is offered to explore special circumstances surrounding a member’s care.

Specialty Nurse Review

HealthHelp nurses evaluate requests, gather additional information and provide approvals for requests that meet clinical guidelines. For requests that fall outside of these criteria, nurses will present an alternative care pathway as guided by the proprietary Clinical Decision Support system. Nurses also provide material about relevant clinical guidelines.

If not approved at the nurse review level, the request is sent for a peer-to-peer consultation.

Peer-to-Peer Consultation

An academically affiliated, board certified, specialty matched, HealthHelp physician expert reviews the request. After consultation with the requesting provider, the request will either be approved by the expert reviewer, or withdrawn/changed by the requesting provider. Our method facilitates a collaborative dialogue between practicing peers that leads to a high-quality care decision for the member.

Value-Based Specialty Benefits Management

The HealthHelp model applies an intuitive and consultative approach to specialty benefits management. For transparency between HealthHelp and the payer, we regularly provide performance reports with clear metrics including analysis of safety and quality improvements in member care, resulting cost savings and ROI. HealthHelp’s proven model helps to curtail specialty-specific utilization and spending, and brings a layer of management that is unsurpassed in the industry.

Quality, Safety, and Cost Savings

Our clinical support and education motivates behavior changes. Physicians learn to request the most appropriate services for members, resulting in improved quality, safety, and long-term outcomes, while delivering savings. HealthHelp’s outcomes research team conducts retrospective studies jointly with the payer, to determine opportunities for improvement in safety, quality, and outcomes. We use the feedback as a model for creation of new value-based programs.

Consult Platform

HealthHelp’s Consult platform ensures rapid response to authorization requests through a consultative and clinical decision support process. This supports our belief that collaboration between payers, providers, and members leads to sustainable and long-term utilization behavior reform.

Platform Overview

  • Web-based workflow processing of Consult requests
  • Multiple service points to meet client and provider needs: Web, Fax, Phone, IVR, EDI
  • Less than 30 seconds average response time on inbound phone requests
  • Automatic escalation to nurses and physician specialists as clinically warranted
  • Case processing within each state’s specific turnaround time guidelines
  • Complete HIPAA Privacy and Security compliance
  • Full URAC and NCQA compliance
  • Web and IVR allow self-service procedure initiation and status checks


Scope is a quality- and safety-based program designed to protect members by reducing unnecessary radiation, repeat studies, and missed diagnoses. The criteria consist of a comprehensive set of policy recommendations that improve safety and quality in image generation and interpretation by ensuring that certain radiologic services are performed and interpreted by trained physicians in accordance with the American Medical Association’s Green Book guidelines.

Program Overview

  • Modalities include CT, MR, PET, nuclear medicine, ultrasound, fluoroscopy, and bone densitometry
  • Quality- and safety-focused to protect patients
  • Reduces unnecessary radiation, repeat studies, misdiagnoses, and missed diagnoses
  • Providers will only be reimbursed for imaging procedures listed on their permitted code lists and for procedures that the consideration process approves the provider to interpret
  • Providers not affected by the program include those that have received proper training within the scope of their residencies, such as cardiologists and orthopedists


HealthHelp offers quality-based, cost-saving site assessment and certification programs that promote best practices in imaging and other specialty services. The mission is to identify opportunities for imaging facilities (including freestanding, hospital-based, and physician offices) to achieve a high level of quality that benefits all members of the healthcare continuum.

Site Assessment Programs include:

Feature Programs include:

  • TherapySite


The Direct program brings together HealthHelp’s Site and Consult programs to complete the cycle of quality and cost-efficient care for health plan members. Through our unique collaborative care model, Direct also helps payers realize significant cost savings.

Direct allows providers to search and refer patients to facilities based on the following criteria:

  • Convenient location
  • Appropriate procedures/services
  • High quality ranking (per the Site certification program)
  • Lower cost for treatment