PPO Bridge

You route the bills. You see the discounts. You own the results.

PPO Bridge sits between your bill review system and the networks that reprice your bills. It handles routing, format conversion, the return path, and the release back into workflow — so PPO savings stop being whatever the platform's built-in repricing happens to produce.

The problem

Built-in repricing decides for you.

When repricing happens inside the platform, you take the result the platform produces. You don't choose which network sees the bill, you don't control the order contracts are evaluated in, and you often can't see why one reduction was applied instead of another.

That's tolerable when you have one network. It's expensive when you have fifty — and it makes it very hard to answer the question a regulator or a client will eventually ask: why was this bill reduced this way?

How it works

Six steps, fully automated.

The bill leaves review, gets priced by an external network, and comes back — without anyone rekeying it or tracking it in a spreadsheet.

  1. 01

    Bill pends for pricing

    A medical bill enters review and is pended to the pricing queue — either by a user or by a Capstone® rule.

  2. 02

    Pended bills are extracted

    A report of pended bills is emitted from the bill review system and picked up by the bridge layer.

  3. 03

    Routing engine selects the bridge

    Each bill is routed to the correct repricer. Different networks, different destinations — decided by rule, not by hand.

  4. 04

    File is built to the repricer’s spec

    The bridge outputs whatever format the repricer requires — 837, XML, CSV, or fixed-width. Their format, not yours.

  5. 05

    Repricer prices the bill

    The third-party network applies its contracted PPO rates and returns a repricing report.

  6. 06

    Rates are applied and the bill releases

    The repriced rates are written back and the bill is released from the pricing pend into normal workflow — or pended again for validation if something needs a look.

Format handling

Every repricer wants something different.

One network wants an 837. Another wants fixed-width. A third has its own XML schema and a fourth will take a CSV if you name the columns exactly right. Normally that means a custom build per network, and a new one every time you add a partner.

The bridge file creator handles the conversion, so adding a network is a configuration change rather than a project.

  • 837
  • XML
  • CSV
  • Fixed-width

Best contract, not first contract

Stacking stops at the first match. That's the wrong place to stop.

Traditional network stacking walks a priority list, applies the first contract that matches, and stops — so the deepest available reduction is only applied when it happens to sit at the top of the list.

We've implemented the alternative on a program spanning more than 50 contracted PPO networks: evaluate every available contracted rate simultaneously, then apply the single deepest reduction to each bill. More savings, no stacking conflicts, and one clean, defensible network rate on every EOR.

The same logic inside SmartAdvisor®

How many networks are you routing today?

If the answer involves a spreadsheet or a manual export, that's the conversation to have.

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