dell healthcare services: staffing and enrollment

Healthcare Staffing ServicesDell Healthcare Services Staffing Services Capability Overview

Dell - Internal Use - Confidential2

Dell Enrollment and Billing Overview


SolutionsRating and quoting

Premium billingand paymentEnrollment and eligibility verification

Key benefits

Life event management

CSR dashboard

Interfaces and integrationCompliance and reportingQuality assurance and testing

Why Dell

Enrollment and billingDell Enrollment and Billing Solution is a robust enterprise integration solution offered for private exchanges to enable secure, real-time quality transactions between health plans, providers and federal/state systems.

We can help you with:

Rating and quoting Premium billing and payment Enrollment and eligibility verification Life event management CSR dashboard Interfaces and integration Compliance and Reporting Quality assurance

and testing




Key benefits


CSR dashboard


Why Dell

Rating and quotingProvides robust solution for quoting new prospects and delivering customized proposals.

• Complies with PPACA*-mandated rules

• Provides seamless and accurate rate processing

• Supports wide range of benefit options for health plan and ancillary products

• Provides detail view of the premium calculations

• Callouts third-party data validation

Key benefits:Calculate premiums based on a robust set of rate attributes

Generate real-time quotes for group and individual members

Take advantage of a flexible, rule-driven rating engine

Determine rates through a flexible rate matrix with multiple family tiering

Design and deploy new plans and bundles easily




Key benefits


CSR dashboard


Why Dell

Premium billing and paymentProvides complete billing, payment collection and premium remittance processing. With full-featured billing and payment, insurers can rely on accurate revenue recognition and receivables management.

• Allows flexible billing cycle schedule

• Displays billing and paymentactivity history

• Provides secure and quick payment process

• Allows payment from multiple sources

• Ensures accurate payment processing, including subsidies

Key benefits:Produce all data needed for billing and remittance

Process annual/retroactive enroll and ad-hoc rate changes and updates

Generate individual, group or split bill to facilitate billing premiums and fees

across multiple entities

Manage complex billing and payment plans

Process electronic/paper form of payment




Key benefits


CSR dashboard


Why Dell

Enrollment and eligibility verificationProvides a modern approach to processing enrollments from state, federal and private exchanges. These services ease the administrative burden of benefits management and reporting while increasing enrollment and participant satisfaction.

• Reconciles plan benefits and rates

• Easily manages and reports on enrollment, participation and accounts

• Customizes data quality and business validation rules

• Provides robust eligibility verification

• Allows easy and fast enrollment and renewal

Key benefits:Simplify group contract and enrollment processing

Support HIPAA 834, 270 and 271 transactions

Synchronize data with internal and ancillary systems

Comply with PPACA enrollment policies and procedures

Reconcile member information with internal and external systems




Key benefits


CSR dashboard


Why Dell

Life event managementProvides complete member and rate change event notification.

• Allows flexible member change event configuration

• Supports 100+ member life event changes

Key benefits:Process life change events under three categories: members, job and retirement

Support proactive and retroactive membership changes due to open enrollment

Configure event for specific set of member and group

Process ad-hoc and annual premium rate changes

Track member reinstatement and demographic changes




Key benefits


CSR dashboard


Why Dell

Customer service representative dashboardProvides comprehensive information about subscriber and their eligibility, billing invoices, payment history and accepts electronic payments (EFT).

• Manages call center productivity

• Accepts EFT one-time premium payment

• Tracks subscriber outstanding premium, payments and adjustments

• Maintains and manages group and member data

Key benefits:Manage customer contacts and issue resolution

Manage member EFT configuration and schedule

Gain single view of member/employee information

Manage appeals and grievances according to policies

Review billing and payment history




Key benefits


CSR dashboard


Why Dell

Interfaces and integrationNo health information exchange is an island. Provides efficient health plan system functionality with seamless integration across federal systems and state agencies and other vendors as appropriate.

• Integrates with claim system for paid thru date processing

• Applies data integrity and business rules up front

• Supports standard and custom integration formats

• Provides outbound and inbound transaction automation

Key benefits:Effectively manage and analyze member interactions and data throughout the life cycle

Integrate with ancillary account receivable and general ledger systems

Execute real-time data integration – scalable to meet high volume

Interconnect seamlessly across multiple exchanges

Take advantage of industry standard integrations




Key benefits


CSR dashboard


Why Dell

Compliance and reportingSupports accurate tracking and reconciliation of payments. A series of standard reports meet most of the required reports used by health plans

• Provides more than 15 standard reports

• Integrates with third-party product by leveraging data and analytics

Key benefits:Generate compliance and regulatory reports

Track metrics through dashboard

Generate enrollment, participation and account report

Provide accurate coverage information to bill accurately for services

Ensure accuracy by integrating a variety of transactional and functional data from key business systems




Key benefits


CSR dashboard


Why Dell

Quality assurance and testingProvides multiple test disciplines and practices to integrate customer-specific test requirements into the overall test strategy.

• Ensures quick, quality implementation withmore than 40,000 ready-to-use test cases

• Tests quality assurance framework for healthcare payer solution

Key benefits:Provide a full range of testing services

Enable strategic test consulting

Execute proven test processes, strategies and governance models

Provide specialized testing services in emerging areas such as mobile, analytical, security, and agile

Deploy ready-to-use innovative test solutions and frameworks




Key benefits


CSR dashboard


Why Dell

Why Dell

Managed individual enrollment and billing for more than 14 health

plans for a state-based HIX

Managed enrollment and billing for Medicare, Medicare Part-D, CHP and HIX LOBs

Processed more than 55 percent of all HIX memberships and benefits for 600,000 members in a large California health plan

Integrated with the data service hub’s direct enrollment

Managed more than 1.3 million

enrollments per annum, with 98

percent of changes processed

within 48 hours




Key benefits


CSR dashboard


Why Dell

E&B key benefits

Speed Efficiency Bottom line

Easily introduce new consumer-driven retail products/plans

Quickly enroll new groups and members

Turn around premiums faster

Streamline invoice processing and receipts

Ensure accurate payments and adjustments

Lower administrative costs/ Increase cash flow

Manage an unlimited number of complex contractual and payment relationships

A nimble architecture that can easily accommodate changes as the healthcare reform evolves

SOA-enabled framework for simple, scalable, and secure interoperability

Comprehensive or modular components to manage all administrative functions


Dell Fraud, Waste and Abuse Solutions Overview


SolutionsFraud, waste and abuse

Coordination of benefits

Subrogation

Consultingand integration

Third-partyrecovery

Utilization management

Fraud, waste and abuseDell Fraud, Waste and Abuse Solutions enable you to capture more revenue and automate payment authorizations with proven toolsets for screening, scoring and coordinating benefits so you can improve payment integrity and boost revenue recoveries.


Improve pre-pay screening for direct savings Use advanced analytics to improve audit and recovery results Increase referrals using provider risk scorecards Reach new markets with predictive modeling and case management Implement best practices across Medicare, Medicaid, and commercial

clients Utilize Dell’s pool of experienced registered nurses, coders, clinicians,

pharmacists, statisticians and data analysts Educate providers on best practices for claims coding and submission




Subrogation


Third-partyrecovery


Fraud, waste and abuseRapidly identify aberrant providers, track member behavior, and use powerful analytics to interrogate pre-payment claims—from prepay through recoveries—and all from a single source. Backed with a team of certified coders and medical professionals.

• Advanced integration best practices and strategic partnerships

• Comprehensive FWA detection, management to improve efficiencies

• Automated Claims Evaluator (ACE, by HMS) to provide complimentary claims analysis

• Expert clinicians and advanced ICD-10 tools to investigate and perform medical necessity and utilization reviews

• Analysis of suspicious incidents across disparate processes and systems

Key benefits:Prepay clinical reviews before payment

Forensic coding and predictive analytics customized to federal/state regulations and plan-specific policies

Incident analytics and reviews of more esoteric services

Investigative support to ensure quality of findings and recoveries

Single source under one roof allows cohesion of communications and results




Subrogation


Third-partyrecovery


Coordination of benefitsAutomate coordination of benefits with other carriers to verify eligibility, coverage and coding, as well as identify overpayment, recoveries or claims paid inappropriately.

• Pioneered solution for Medicaid in 1985

• Applied knowledge to Medicaid MCOs in 2005; now working with nearly 250 Medicaid MCOs

• Can recover 2% of total spend and generate a 5:1 ROI on cost avoidance

Key benefits:A verification approach

Accurate identification between primary and secondary payers

Expedited recovery

Claims re-verification

An improved payer of last resort status




Subrogation


Third-partyrecovery


SubrogationOrchestrate accurate recovery and payments from a variety of information sources through improved data mining and billing.

• Covers all types of claims, including casualty and workers compensation

• Rule-based triggers and algorithms, behavioral analysis, and statistical data analysis

• Maestro state-of-the-art case management system

Key benefits:Easy, secure 24x7 Internet access

Real-time updates

Paperless process via imaged documents

Automated prompts that drive workflow

Little or no need for internal IT support




Subrogation


Third-partyrecovery


Third-party recoveryIdentify and coordinate the responsible party for primary payment of claims to prevent or reduce payment/overpayment of claims, as well as research and capture payments, settlements, judgments and reimbursements to compensate for losses.

• Clients save more than $7 billion per year through our cost avoidance services

• Largest database of eligibility information in the nation; receive enrollment files from more than 1,000 insurance plans with more than 1B segments of coverage

• Recovery provided to more than 40 Medicaid agencies and numerous commercial plans

Key benefits:Proprietary data mining techniques applied to identify member coverage with other payers (Medicare, TRICARE, commercial)

Initiate recovery via direct billing or disallowance

Case management of all coverage information to avoid paying claims when another party is liable




Subrogation


Third-partyrecovery


Utilization managementControl the authorization and best use of benefits through licensed care managers, nurses, physicians and other key clinicians. Evidence-based clinical guidelines drive high-quality care through tools such as care pathway tables, flagged quality measures and integrated medical evidence.

• Uses care guidelines from MCG Health (former Milliman Care Guidelines) for length of stay, days/1000, admits/1000, which defines evidence-based best practices

• Oversees prospective, concurrent, and retrospective reviews

• Provides DRG validation, quality of care, bill audits

• URAC-accredited registered doctors and nurses

Key benefits:Standard week-day call center along with urgent call center available 24/7 for weekend emergency pre-certifications and appealsExperienced case/care management nurses with active licensure in the state of practice, diverse medical backgrounds and at least five-years clinical experience

Intake coordinators with four-year degrees, prior call center experience, and/or medical coding/terminology knowledge

Automated triggers in the system to identify members who may benefit from case management intervention

Offer flexibility to customize group-specific business rules




Subrogation


Third-partyrecovery


Consulting and integrationProvide ongoing support and subject matter expertise to analyze existing or needed systems for client-specific industry-leading solutions.

• Clear understanding of system portfolio creating deep insight into the present state

• Roadmap and plans based on the present state account for actual processes and assets in use

• Comprehensive inventory of assets and interdependencies allows for clear planning and integration

Key benefits:Dell Business Process Management System dashboards

Review of existing systems

Data and systems integration


Dell Staffing Services Overview


SolutionsStaff augmentation services

Managed services

Business process outsourcing

System conversion support

Staffing services overviewDell Staffing Services drives results with innovative, cost-efficient staffing solutions. Team up with Dell Healthcare to get the staff you need, when you need them, where you need them, and for as long as you need them.


Customer service staffing and management

Front-end processing and data entry Eligibility and enrollment administration Claims processing and adjustments Pend management claims adjustments Insurance verification User acceptance testing

Business analysts Project management Configuration services Certified coders Quality assurance claims audits Consulting services for objective

operational review



Managed services



Staff augmentation servicesDrive results with innovative, cost efficient staffing solutions.

• Flexible to meet your project and budgetary needs

• Trained associates which decrease training and ramp-up time

• Short and long-term assignments

Key benefits:Comprehensive database of more than 46,000 candidates

More than 30-years experience providing claims professionals to the healthcare payer industry

Experience with multiple claims systems

End-to-end staffing: mailroom support and front-end data entry, claims adjudication, audit/overpayment recovery, inbound and outbound member and provider call center staff

Local on-site, work at home, travel resources, as well as contract-to-hire and direct-hire solutions



Managed services



Managed servicesReduce your administrative costs and enhance operational efficiency. Outsource any or all of your transactional or call center operations to Dell.

• Dell manages the day-to-day activity and outcomes for performance, productivity, and quality assurance

• Integration with customer leadership team

• Leverage global delivery model for reduced costs

Key benefits:Provides a project management approach

Delivers outcomes/results-based solutions

Leverages customer’s existing systems and technology

Incorporates quality process improvement and management in the solution

Delivered through Dell service centers or via home processing



Managed services



Business process outsourcingDell’s end-to-end BPO services for healthcare payers are designed to meet the challenges of regulatory mandates of the Affordable Care Act and others – the transition to ICD-10 , changing member demographics, and rising consumerism.

• Improve member services and gain a competitive advantage

• Decrease operational costs

• Meet peak demand for trained resources during ICD-10 conversion, open enrollment, or unexpectedly high claims or call volume, through our staff augmentation services

Key benefits:Process transformation

Consulting, implementation and managed services

Ready-to-market, standardized solutions

Multi-tenant models for COOPs and ACOs

Global network of professionals in Plano, TX; Lincoln, NE; Chennai, Coimbatore; Noida, India and Manila, Philippines



Managed services



System conversion supportDell can assist with system selection, implementation, data migration and claim processing support to ensure prompt payment guidelines are met.

• Helps manage the cutover expense related to facility, equipment, and staffing

• Reduces time to return to full productivity

• Provides flexible and scalable solutions to match business needs

Key benefits:Allows the health plan to focus on system transition, maximizing return on investment (ROI)

Reduces risk of building claims backlog during system transition

Provides flexible duration

Maximizes new system ROI

Delivered through Dell service centers, remote work-at-home processing, or customer site

Thank you!Visit Dell.com/HealthPlans to learn more.

4 of 4