Why choose HealthHelp?

The difference between traditional specialty benefits management and us.

Educational and Collaborative
 

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

Long-Term Outcomes
 

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

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.

Cardiology

Radiology

Oncology

Musculoskeletal

Sleep Care

Cardiology Program

$444Billion

Annual Cost of Cardiovascular Disease in the US

Imaging | Interventional | Devices

HealthHelp was the first in the industry to introduce comprehensive cardiology benefits management, including diagnostic testing, interventional procedures, and cardiac devices. The program works to deliver the most appropriate utilization of services for a variety of conditions before and after diagnosis.


Program Results

HealthHelp was given a 99% satisfaction rating among providers. Since program inception in 2009, our process has resulted in:

  • 15-20% reduction in unnecessary Percutaneous Coronary Interventions (angioplasty and stents)
  • 15-20% reduction, over 5 years in diagnostic catheterizations without having any prior non-invasive imaging
  • 5% reduction, over 3 years in monthly length of use for wearable cardioverter defibrillators
  • Enhanced quality care and member safety while reducing utilization
  • Reduction in repeat cardiac imaging and inappropriate utilization of cardiology services
  • Collaborative peer-to-peer reviews by academically affiliated specialists

Patient Clinical Information*

 
  • Patient diagnosis
  • Clinical indication
  • Test ordered
  • Reason for test
  • Patient symptoms and duration
  • Laboratory studies
  • Prior treatments
  • High or low-risk indication
  • Supporting clinical information

Automated Decision Support

Providers submit procedure requests. If the request meets evidence-based criteria, it is automatically approved.

If the request falls outside of pre-set clinical guidelines, it is sent to nurse review.

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.

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

Peer-to-Peer Consultation

A HealthHelp physician 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.

Medically Appropriate Procedures*

  • Cardiac Catheterization
  • Echocardiography
  • Stress Echo
  • Cardiac Ablation
  • Electrophysiologic Testing
  • Doppler Flow of Extremities
  • Percutaneous Coronary Intervention (PCI)
  • Implantable Cardiac Defibrillators
  • Implantable Cardiac Pacemakers
  • Cardiac Re-synchronization Therapy (CRT-D)
  • Cardiac Re-synchronization Therapy (CRT-P)
  • Cardiac Durable Medical Equipment
  • Cardiac Left Ventricular Pacing Electrode Add-on
  • Left Ventricular Assist Devices (LVADs)
  • Loop Recorder Implants
  • Cardiac Wearable Cardioverter-Defibrillator (WCD)
  • Cardiac CT
  • Cardiac CT Angiogram (CCTA)
  • Cardiac MRI
  • Cardiac PET
*Lists not comprehensive

Radiology Program

$100Billion

Annual Cost of Medical Imaging in the US

Appropriate Imaging and Reducing Radiation Exposure

HealthHelp increases patient safety by reducing radiation exposure and provides savings by improving overall quality of care.


Program Results

  • 14% reduction in unnecessary radiation exposure
  • Integrated with Oncology Program to enable timely provider outreach
  • Sustainable, long-term cost savings
  • Lasting education and provider ordering optimization
  • Radiology facility certification with DiagnosticSite’s stringent criteria
  • Management of provider self-referral behavior
  • Improved imaging quality (DiagnosticSite) and interpretation by ensuring that specialized and trained physicians perform review of imaging studies (Scope)

Patient Clinical Information*

 
  • Patient Diagnosis
  • Clinical Indication
  • Test Ordered
  • Reason for Test
  • Patient Symptoms and Duration
  • Laboratory studies
  • Patient Medications and Duration
  • Prior Treatments
  • Summary of Clinical Findings

Automated Decision Support

Providers submit procedure requests. If the request meets evidence-based criteria, it is automatically approved.

If the request falls outside of pre-set clinical guidelines, it is sent to nurse review.

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.

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

Peer-to-Peer Consultation

A HealthHelp physician 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.

Medically Appropriate Procedures*

  • CT
  • CTA
  • CT Bone Density
  • Cardiac Ablation
  • Interventional Radiology
  • MRA
  • MRI
  • MRS
  • fMRI
  • Nuclear Medicine
  • PET Scan
  • SPECT
  • Doppler
  • Ultrasound
  • 3D Mammography

*Lists not comprehensive

Oncology Program

$157 Billion

Annual Cost of Cancer Care in the US

Integrated Oncology | Medical/Surgical Services | Virtual Tumor Board | Radiation Therapy

HealthHelp educates providers across all involved specialties to provide high quality cancer care through the entire life cycle of oncology diagnosis, simulation, optimization, and surveillance. By implementing evidence-based guidelines and working with providers during the Consult process, treatment decision planning is as accurate as possible and members receive the appropriate services that optimize outcomes.


Program Overview and Consultative Process results in:

  • Evidence-based interventions during diagnosis and treatment
  • Appropriate use of radiographic, biomarker, molecular risk assessment, genetic, and other testing
  • Alignment of primary care, radiation & medical oncology and surgical interventions to seamlessly manage the episode of care
  • Identification of at-risk patients through advanced treatment planning, bridging gap between screening/diagnostics and treatment planning
  • Increased clinical efficiency, generating operational and financial savings for payers
  • Quality outcomes and reduced risk of future complications

Member Clinical Information*

 
  • Patient Diagnosis or Clinical Indication
  • Treatment Requested
  • Radiation Number of Fractions
  • Total Radiation Dose
  • Cycle Length
  • Number of Cycles Requested
  • Prior Surgical Intervention
  • Metastasis
  • Prior Radiation Treatment
  • Prior Chemotherapy
  • Cancer Staging
  • Dose per Fraction
  • Type of Radiation Therapy
  • Prior Surgical Intervention
  • Prior Radiation Treatment

Automated Decision Support

Providers submit procedure requests. If the request meets evidence-based criteria, it is automatically approved.

If the request falls outside of pre-set clinical guidelines, it is sent to nurse review.

Specialty Nurse Review

HealthHelp nurses evaluate requests and provide approvals for treatments within clinical guidelines. For procedures that fall outside of these criteria, nurses will discuss an alternative care pathway.

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

Peer-to-Peer Consultation

A HealthHelp physician 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.

Medically Appropriate Procedures*

  • Chemotherapy
  • Intensity-Modulated Radiation Therapy (IMRT)
  • Brachytherapy (including interstitial, intracavitary, intra-arterial)
  • Biological Agents
  • 2D/3D Conformal Radiation
  • Radiation
  • Hormonal therapy
  • Supportive care and ancillaries
  • Prophylactics
  • Screening & imaging
  • Stereotactic Brain & Body Radiosurgery
  • Proton Beam Therapy

Additional Services Addressed in Consult Discussion *
  • Palliative care
  • Precision testing
  • Genetic testing
  • Growth factor support
  • Treatment planning decisions
  • Supportive care/pain management considerations

*Lists not comprehensive

Musculoskeletal Program

$950Billion

Annual US Direct and Indirect Costs for Bone and Joint Health

Including Spine and Orthopedic Implant Management

HealthHelp provides a fully integrated pain, spine, musculoskeletal, and orthopedic implant program for management of chronic pain and bone and joint health.


Program Overview

Utilization of proprietary guidelines developed from published clinical evidence-based studies

  • >10% impact on MSK surgeries
  • >25% impact on inpatient redirection
  • >6% impact on pain management
  • Increased appropriate use of physical therapy with proven improvement in patient outcomes
  • Significant overall decrease in surgical interventions and implants
  • Greater consumer engagement via effective member-centric health and wellness and incentive programs
  • Specific decrease in low-back pain-related spinal interventions
  • Improvement in quality and safety for members thus qualifying for the MLR requirement under ACA law

Member Clinical Information*

 
  • Member history (falls, injuries, or stress)
  • Onset of pain
  • Direction of pain
  • Nature of pain (shooting, stabbing)
  • Relief/aggravation causes
  • Differentiation of pain
  • Other member symptoms
  • Current or suspected diagnosis
  • Clinical indication
  • Summary of Clinical Findings (range of motion)
  • Radiologic findings (joint space preservation)
  • Functional assessment
  • Reason for test
  • Test ordered
  • Treatment, procedure, or device Requested
  • Member medications and duration (use of analgesics)
  • Prior medical management history
  • Prior use of injectables and branch blocks
  • Prior invasive procedures or surgeries

For The Evaluation Of:
  • Osteoarthritis (OA)
  • Rheumatoid arthritis (RA) and juvenile RA (JRA)
  • Avascular necrosis (AVN) or osteonecrosis (ON)
  • Congenital dislocation of the hip joint (CDH)
  • Hip dysplasia
  • Acetabular dysplasia (shallow hip socket)/protrusion
  • Benign and malignant bone tumors
  • Paget’s disease arthritis
  • Ankylosing spondylitis
  • Frozen, stiff, loose joint
  • Traumatized and malaligned joint
  • Fractures

Automated Decision Support

Providers submit procedure requests. If the request meets evidence-based criteria, it is automatically approved.

If the request falls outside of pre-set clinical guidelines, it is sent to nurse review.

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.

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

Peer-to-Peer Consultation

A HealthHelp physician 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.

Medically Appropriate Procedures*

The program covers the use of diagnostic procedures, invasive interventional procedures, PT/OT therapies, injectables, prostheses, and surgical implantable devices.

Non-Surgical Pain Management:
  • Physical Medicine Pain Treatments
  • Epidural Steroid Injections
  • Facet Joint and Medial Branch Blocks
  • Sacroiliac (SI) Joint Injections
  • Intrathecal Morphine
  • Intrathecal Morphine Pump
  • Spinal Cord Stimulators (neurostimulators)

Surgical Pain Management:
  • Artificial Disc
  • Intrathecal Pain Pump
  • Kyphoplasty/Vertebroplasty
  • Lumbar Discectomy
  • Lumbar Endoscopic Discectomy
  • Lumbar Foraminotomy
  • Lumbar Foraminotomy/Facetectomy
  • Lumbar Fusion
  • Lumbar Laminectomy
  • Minimally Invasive Lumbar Surgery
  • Spinal Cord Stimulator

Spine Management/Hip and Knee:
  • Single and Double-Lock Screw Systems
  • Spinal Corpectomy Cages
  • Cervical Plate Systems
  • Steffee Implants
  • Harrington Implants
  • Neurostimulators (Spine)
  • Drug Infusion Systems (chronic pain, spasticity)

Upper Extremity, Wrist, Femur, Tibia, Shoulder, Elbow, and Foot:
  • Myoelectric prosthesis
  • Body-powered prosthesis
  • Constrained vs. Unconstrained
  • Condylar blade plate
  • Grosse-kempf (GK) nail
  • Buttress plate
  • Neer’s prosthesis
  • Souter’s prosthesis
  • Baksi’s prosthesis
  • Single axis
  • SACH Dynamic response

*Lists not comprehensive

Sleep Program

$66Billion

Annual US Direct and Indirect Costs for Sleep Disorders

Obstructive Sleep Apnea (OSA) | Non-OSA | Sleep Disorders

HealthHelp has identified a unique opportunity in the overall management of sleep disorders, resulting in the most appropriate care delivered to members with a comprehensive approach to cost savings and care management.


Program Overview

  • Collaborative care approach that helps physicians choose the most medically appropriate in-home or in-lab diagnostic sleep study guided by evidence-based criteria
  • 46% increase in In-Home Sleep Study Utilization trend
  • 25% Conversion to In-Home for Suspected OSA population
  • Elimination of unnecessary testing for detection of low-to-severe sleep apnea, improving diagnostic efficiency and treatment
  • Increased safety and quality of care for the patient while achieving sustained savings for the payer
  • Reduced double testing rate for patients who receive in-home testing first, followed by an in-lab
  • Compliance CPAP/BiPAP therapies
  • Ensuring that in-lab sleep tests are received in certified facilities assessed for safety and quality

Member Clinical Information*

 
  • 20 uniquely developed OSA assessment criteria
  • Member Suspected or Current Diagnosis
  • Clinical Indication
  • Test Ordered
  • Treatment Requested
  • Member Medications and Duration
  • Prior Treatments
  • Summary of Clinical Findings
  • Reason for Test
  • Member Symptoms

Automated Decision Support

Providers submit procedure requests. If the request meets evidence-based criteria, it is automatically approved.

If the request falls outside of pre-set clinical guidelines, it is sent to nurse review.

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.

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

Peer-to-Peer Consultation

A HealthHelp physician 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.

Medically Appropriate Procedures*

  • In-Home Polysomonography
  • In-Lab Polysomonography
  • Sleep Site – safety & quality certified Sleep labs
  • C-PAP Compliance

*Lists not comprehensive

 

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

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

Site

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

Direct

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