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HEALTH Claim COST CONTAINMENT SOLUTIONS for Tpa’s. Presented by London Medical Management, Inc. DISCUSSION. Health Claim Cost Containment Solutions Unique combination of Health Claim Negotiations with PatientPAL TM advocacy services. In-network Claims : PHCS Multi-plan Three Rivers

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Health claim cost containment solutions for tpa s

HEALTH ClaimCOST CONTAINMENT SOLUTIONS for Tpa’s

Presented

by

London Medical Management, Inc.


Discussion
DISCUSSION

  • Health Claim Cost Containment Solutions

  • Unique combination of Health Claim Negotiations with PatientPALTM advocacy services


Health claim negotiations 2 buckets of claims

HEALTH CLAIM NEGOTIATIONS

2 Buckets of Claims

  • Out-of-network Claims:

  • No network affiliation

  • No discounts


Hospital stop loss provision protects the hospital not the client

HOSPITAL STOP LOSS PROVISION

Protects the Hospital, NOT the Client

***Once Billed Charges reach the Stop Loss amount ($50,000 in this case), hospital Reimbursement reverts from Per Diem to a Percentage of Billed Charges (usually 40% discount)

***Example above: Average Daily Reimbursement is $7,200


Health claim negotiations 2 buckets of claims1

HEALTH CLAIM NEGOTIATIONS

2 Buckets of Claims

  • Out-of-network Claims:

  • No network affiliation

  • No discounts


Health claim negotiations process

  • Pend:

    • ALL in-network claims that reach $10,000*** level

    • ALL out-of-network claims

  • All Claims must be pended BEFORE they are paid

  • ***Threshold levels may be adjusted to maximize client savings

HEALTH CLAIM NEGOTIATIONS

Process


Health claim negotiations process1

  • CLAIM from TPA

  • UB 92/HCFA 1500

  • ASC II File Format

  • In/Out of network

  • indication

  • Provider Contact

  • agreements are negotiated one

  • claim at a time

HEALTH CLAIM NEGOTIATIONS

Process

  • Provider Charges (Research)

  • based on geographic

  • location of the facility/provider

  • - Historical negotiations data

  • LMM Claim Fact Sheet

  • claim details extracted

  • from info provided by

  • TPA



Health claim negotiations claim fact sheet

HEALTH CLAIM NEGOTIATIONS

Claim Fact Sheet


Health claim negotiations claim fact sheet1

HEALTH CLAIM NEGOTIATIONS

Claim Fact Sheet


Claim negotiations protocol

  • In-network Claims:

    • Claims < $10,000*** should be processed according to

    • the network contract

    • Claims > $10,000*** will be sent to LMM for review

  • Out-of-Network Claims (include “wrap” networks):

    • ALL out-of-network claims will be sent to LMM for review

    • ***Threshold levels may be adjusted to maximize client savings

  • Claim Negotiations Protocol


    *Negotiations for a Fortune 500 company working with a nation’s leading health plan

    **PLAN Allowable includes discounts available through associated networks



    Patient pal tm

    PATIENT PALTM


    Patient pal care continuum

    Well Patient Entry and their covered family members when faced with:

    • Patient PAL - 24/365

    • Physician Referral

    • 2nd opinion

    • Emergency transportation

    • COE/Hospital Admission Assistance

    • Pricing Negotiation

    Acute Patient

    HRA

    Patient PAL Care Continuum

    At Risk Patient

    Identification

    Large Claim Assistance

    • Outreach & Coaching

    • Comprehensive

    • Physical Exam

    • Physician Referral

    • Disease Management

    • Engagement

    Pre-Admission

    Post Discharge


    Electronic medical record emr

    Patient Record Face Sheet and their covered family members when faced with:

    Electronic Medical Record (EMR)


    Patient referral source

    Patient Referral Source and their covered family members when faced with:


    London medical management contingency fee

    • Health Claim Cost Reduction: and their covered family members when faced with:

    • Percentage of documented savings

    • Patient PAL services available to all covered

    • members on as needed basis

    London Medical Management

    Contingency Fee


    What we help you achieve
    WHAT WE HELP YOU ACHIEVE and their covered family members when faced with:

    • Decrease the total cost of health care through direct negotiations of individual patient claims

    • Enhanced service by accessing Patient PAL for employees makes TPA’s more competitive against carriers


    Our value proposition
    Our Value Proposition and their covered family members when faced with:

    • We assist TPA’s and employers to reduce the cost impact of large claims through direct negotiations with providers. We utilize the savings from these negotiations to help employees and their dependents navigate the complexities of the healthcare system through our Patient PAL program.


    Our clients include

    Our Clients Include: and their covered family members when faced with:


    Summary
    SUMMARY and their covered family members when faced with:

    • Health Claim Cost Containment Solutions

    • Unique combination of Health Claim Negotiations with Patient PALTM advocacy services


    Next steps
    NEXT STEPS and their covered family members when faced with:

    • Implementation:

      • Business Associate Agreement between TPA and LMM

      • Claims negotiation protocol implementation with the Health Plan

      • Non-disclosure Agreements


    Frequently asked questions
    Frequently Asked Questions and their covered family members when faced with:

    Q: How are negotiations done?

    A: Knowledge-based negotiations with information available through internal negotiation database.

    Q: Is existing discount negated?

    A: Existing discount is never negated. That’s why allowable amount is critical to have so that LMM negotiates an additional

    discount.

    Q: Who pays LMM fees?

    A: Client pays LMM fees.

    Q: What is the provider payment monitoring system?

    A: Once negotiations are complete LOA is sent to client TPA for payment; LMM reaches out to provider to verify receipt of

    payment.

    Q: How is the claim information exchanged?

    A: Excel format, usually exchanged through client’s FTP/secured server.

    Q: How often is client invoiced?

    A: Monthly


    Frequently asked questions1
    Frequently Asked Questions and their covered family members when faced with:

    Q: What is included in the invoice?

    A: All negotiated claims showing Billed Charges, Allowable, Final Payment and Savings.

    Q: How long is the set-up process?

    A: Usually two weeks from signature of all agreements.

    Q: Is Allowable or Payment negotiated?

    A: Negotiations are based on Allowable amounts.

    Q: What happens to patient responsibility, deductible and/or co-insurance upon successful completion of

    negotiations?

    A: Patient responsibility still applies.

    Q: What are the next steps?

    A: Health Plan LOI; BAA; Contract with LMM; analysis of health claims retrospectively to show potential

    savings had LMM been involved.

    Q: How does Patient PAL work with Case Management or does it replace it?

    A: Patient PAL does not replace but rather enhances Case Management, where Case Management serves as

    authorization entity and Patient PAL serves as facilitator of prompt and best medical care.


    Lmm contact info
    LMM Contact Info and their covered family members when faced with:

    Corporate Headquarters

    Contact: Jack G. London, President/CEO

    Phone: 702-737-7555

    Fax: 702-737-7504

    Address: 11920 Southern Highlands Pkwy Suite 103

    Las Vegas, NV 89141

    www.LondonMedicalManagement.com

    www.PatientPAL.org


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