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Healthcare Services Division Healthcare Payer Services

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Page 1: Transnational Payer Services

Healthcare Services Division

Healthcare Payer Services

Page 2: Transnational Payer Services

Corporate Profile

TBS – Healthcare Services

Payer Services

Healthcare - Payer Services

Enrollment & Eligibility Management

Claims Management

Payment Integrity Audit services

‣ Overpayment Recovery

‣ DRG Compliance Audit

Key Differentiators

Value Proposition

Contents

Page 3: Transnational Payer Services

Corporate Profile

Inception

Global Delivery Centers

Clients profile

Service Portfolio

Data Security

Quality

Delivery

Founded in 2006; headquarters in NY

Near shore and Off Shore delivery centers, Headquarters based in NY and delivery centers in both US and India

Clients range from Small entities to Fortune 100 organizations

HealthCare & Insurance – Payer & Provider services

ISO/IEC 27001:2005 (BS 7799 - Information Security Management System [ISMS] Certified) security standards.

HIPAA Compliant Organization

Six Sigma based methodologies for Transition, Quality & Process efficiency & LEAN programs for process improvements

Global Delivery Model, which delivers 24 X 7 services

Page 4: Transnational Payer Services

TBS-Healthcare Services

FEATURES

• End-to-end services on both the Payer & Provider domains

• Expertise spanning the entire gamut of services ranging from simple transaction based services to

high-end audit, research & analytics.

• Proficiency in niche segments such as Payment Integrity Audit, Claims Administration, Code

Review Audit, DRG Audit etc.

Page 5: Transnational Payer Services

TBS - Payer Services

Enrollments - New Enrollments

& updates maintenance

Eligibility Management

Pre-Ex & COB information

verification

POLICY ADMINISTRATION

Out-of-Network Claims Negotiation

Support

Provider Contracting

Contract Maintenance

NETWORK MANAGEMENT

Provider updates & Data

maintenance

Facility Data maintenance

Manual Provider matching

Provider Credentialing Support

PROVIDER DATABASE MANAGEMENT

Claims Data Entry

Pre-Adjudication

Claims Adjudication services

International, RX & CDH claims

processing

Claims Re-pricing

Claims Adjustments

CLAIMS MANAGEMENT

Physician Referral review process

Pre-auth generation

Inpatient Admission notification

UTILIZATION MANAGEMENT

Payment Integrity Audit

(Overpayment Recovery) Services

Claims Reconsideration

Hospital Bill Audit

Code Review & DRG Audit

PAYER ANALYTICS

Our current experience in the Payer domain comprises of service

offerings in the following process areas

Page 6: Transnational Payer Services

Eligibility & Enrollment Management

FEATURES

6 years of experience in Enrollment services for a TPA.

TBS handles the following as part of Policy administration:

New enrollments

Changes

Run-in plan inclusions

Terminations

Member Eligibility Verification, as an allied function of Overpayment Recovery

Services verifying the Medicare/Commercial eligibility for members

Determination of primary & secondary claim payment responsibilities

Source data to establish if the member has any other insurance coverage

Identify overpayments due to incorrect co-ordination of benefits between primary &

secondary insurers

Dependent Eligibility Audit to identify ‘ineligible’ dependents, vis-à-vis the plan’s

eligibility requirement

Page 7: Transnational Payer Services

Value Proposition-Member Enrollment & Eligibility

Business

Process

Page 8: Transnational Payer Services

Claims Management Services - Overview

TBS currently offers the following services within the Claims / Revenue Management services, on the Payer side.

TBS users login remotely to the client servers, through a secure connection, & access the data needed to perform

the various functions.

Page 9: Transnational Payer Services

Value Proposition – Claims Adjudication

- Resource optimization through

strategic utilization of internal

resources

- Prevention of possible over

payments & first level claim appeals

- Operational cost savings in the

range of 30-50%, on existing costs

- 60% reduction in training costs

- Plan & prioritize the claim volume

to coincide with scheduled check-

runs

- Flexible operations to meet urgent

requirements

- Faster Turn around times

(improvement of over 33% )

- Higher accuracy rates (exceeding

99% on financial & 98% on

procedural accuracy)

Adjudication

Business

Process

Page 10: Transnational Payer Services

Payment Integrity Audit Services-Overview

TBS currently offers a comprehensive suite of Payment Integrity Audit services.

Page 11: Transnational Payer Services

Overpayment Recovery Services- OverviewSNAPSHOT

Experience in the Overpayment Recovery Services for a leading national insurer – includingclaims review as 2nd or 3rd pass vendor

Identified over $200 Mm for our partner, of which approximately 60-70% of the overpayments($125 - $150 Mm) were identified as part of 2nd/3rd pass review

Reviewed & analyzed 200,000 claims per year, and identified overpayments resulting fromincorrect contractual reimbursement, billing & coding discrepancies and incorrect co-ordination of benefits

Overpayment ratios of 8-10% in professional claims & 5-7% of institutional claims

Overpayments ranging from $50 to $5,000 (Professional claims) & $1,000 to $500,000(Facility claims)

APPROACH & METHODOLOGY

Comprehensive 360 degree analysis covering aspects of Bill review, Code review, DRG review,Contractual reimbursement & Coordination of Benefits

A dedicated team to identify low $ refunds, which would not have been cost-effective for theonsite analysts

Identification of fraudulent & abusive provider practices, resulting in claim overpayments

Trained and certified work force that comprises of qualified Medical Doctors and CertifiedMedical Coders

Page 12: Transnational Payer Services

Overpayment Recovery Services – Process FlowTBS endeavors to maximize overpayments’ identification through optimized efforts. We

partner with our clients to combine robust data mining techniques with deep domain

analysis, to achieve this objective.

• Process

Migration

• System

Training

• Process

Documentation

& Client sign-

off

Knowledge

Transfer

• Data feed of

paid claims

• Data Mining &

retrieval

• Claims

segregation &

prioritization

Data

Analysis

• Analysis of

paid claims

• Identification

of over-

payments

• QA process

Claims

Audit

• Provider

Contact -

Recoupment

(Offsetting

future

payments)

• Provider

follow-up &

recovery

Overpayment

Recovery

Page 13: Transnational Payer Services

DRG Compliance Audit

Approach & Methodology:

360 degree retrospective review of claims, going beyond tool based insights &

predictive analytics, augmented by ‘deep-dive’ manual analysis

Medical Code Editor (MCE) support to review medical records for compliance

Data quality reviews on inpatient records to validate the ICD-9-CM codes, DRG

group appropriateness, missed secondary diagnoses and procedures, and ensure

compliance with all DRG mandates and reporting requirements

Continuous evaluation of the quality of clinical documentation

Review of medical records & corresponding documentation for completeness,

accuracy and compliance

Recommendations for revised DRG assignment, supported by medical records

Review of

Medical

charts

Research &

Analysis

Summary of

Audit

findings

Provider

Education

Page 14: Transnational Payer Services

Value Proposition – Payment Integrity Audit

Business

Process

Page 15: Transnational Payer Services

Healthcare - Key Differentiators

A decade of proven service track record

End-to-end expertise on Payer and Provider domains

Expertise spanning across the value chain rangingfrom low-end transaction services to high-end audit &analytical services

Thorough understanding of the claim life cycle,enabling us to understand the nuances of ClaimsManagement

Experience & expertise in the niche segments of CostContainment, Out-of-Network Claims settlement &Pharmacy benefits domains

Experienced staff comprising of certified analysts &Professional Medical doctors as DRG coders

Customer satisfaction through our ability tothoroughly understand the client businessrequirements and highly effective delivery capabilities

High client retention ratio

Identified overpayments of over $200Mm, as part of our Payment Integrity Audit services

Identified recurrent patterns in provider billing resulting in overpayments of over $7.5 mm , in the

NICU claim scenario

Discovered uncharted claim scenarios for billing & coding inconsistencies in Mental health, and

Dialysis claims (Epogen & Epoetin administration)

Achieved cost savings of over 40% & Improvement in TAT of 33% on existing parameters

Benefits to Clients

Page 16: Transnational Payer Services

Value Proposition

Value Proposition

Revenue enhancements & cost optimization

Improve Billing & Coding compliance

Identify fraudulent billing/coding practices & prevent wasteful expenditure

Experience in the Payment Integrity Audit services, recovering overpayments of over $200 Mm

Comprehensive domain expertise spanning the entire spectrum of Payer-Provider services

PROCESS

ENHANCEMENTS

BUSINESS

PROCESS

OPTIMIZATION

CROSS

FUNCTIONAL

EXPERTISE

Page 17: Transnational Payer Services

Redefining Business Approach

Building Relationships

Learning Together

Knowledge Management

Process Improvements

Productivity Gain

Performance and Profitability

Organizational Fit

Openness and Accountability

Ownership and Responsibility

BEST

POSSIBLE

OPTION

Page 18: Transnational Payer Services

Building RelationshipsLearning TogetherKnowledge Management

Contact me today to find out how TBS and

our solutions can improve your bottom line

with no upfront fees!

Tim Kirsch

Consulting Partner

Transnational Business Solutions, LLC

45 West 34th Street Suite 1107

New York, NY 10001

800-362-8691

[email protected]