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a solution for all self funded clients
A solution for all self-funded clients
  • In the evolving world of health care, UMR is a sophisticated partner who understands the marketplace and can provide innovative responses to new regulations, industry trends and customers’ changing needs. We have seen everything the market has had to offer, and we’ll work with you to incorporate new solutions, realize additional efficiencies and develop a long-term vision for helping you grow and adapt.
  • Clients come to us because they are looking for a strong partner who listens … who can help them design a benefit plan that works specifically for their unique situation … who delivers financial and claim accuracy … who offers a service model based on — well, service.
  • More than 95 percent of our clients not only renew with us, they recommend us to other organizations. They appreciate the exceptional service, solid savings and thought leadership UMR offers.
  • UMR is a great solution for all self-funded organizations.
  • Additionally, we have a particular understanding of some specific industries:
    • Hospitals and health care systems - Expertise on supporting three- and four-tier designs, promotion of domestic utilization
    • Native American - Expertise on coordinating Medicare-like rate re-pricing, domestic pharmacy pricing, hybrid care management models
    • Labor/trusts - Expertise on collectively bargained welfare benefit plans
    • Retirees - Expertise on working with retirees, dedicated claim teams with specialized training
    • Coalitions - Experience and expertise on the complex relationships and value of coalition members
    • Public sector - Experience and expertise working with states, cities, counties and school districts
tribal market expertise
Tribal market expertise
  • UMR administers employee benefits for customers ranging from small tribal nations and gaming enterprises to statewide tribal health consortiums. We have a team of American Indian and Alaska Native market experts and offer you a dedicated service team trained in the specifics of your plan.
  • We offer market-specific solutions based on:
    • Providing quality health care to tribal members while effectively increasing provider access and managing plan costs
    • Ensuring efficient, accurate claims payment and coordinating Medicare-like rate (MLR) repricing, if applicable
    • Advancing the use of existing tribal health resources and traditions
    • Reducing the administrative burden of day-to-day health plan management
    • Offering customized tools and resources for stronger education and health promotion
sample tiered plan designs
Sample tiered plan designs
  • Customers that operate tribal health centers can benefit from multi-tiered plan designs. The most common is a 3-tier plan, with services from your tribal health center providers paid at Tier 1, in-network providers at Tier 2 and out-of-network providers at Tier 3.
  • UMR can administer plans with any number of tiers.
  • For instance, if your tribal health center is unable to provide a particular service, UMR can set up your plan to pay for such services at the Tier 1, domestic, level to ensure your employees and their dependents are not penalized.
  • Another option is to mandate that a specific service be provided at your facility. Members still can receive the service at other facilities, but it would paid at the Tier 3, out-of-network, level.
medicare like rate mlr entitlement
Medicare-like rate (MLR) entitlement
  • UMR can provide Medicare-like rate repricing (MLR) and claim payment for in-network services, in compliance with Indian Health Services (IHS) and Contract Health Service (CHS) requirements.
  • The MLR entitlement offers potential savings for eligible hospital care provided to individuals of American Indian descent through Medicare-participating hospitals. These services may include inpatient, outpatient and skilled nursing facility care.
  • The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ruled that tribal members obtaining health care at Medicare-participating hospitals pay no more than Medicare designated prices for their health care services. Hospital facilities charge far more than the MLR, so it is in the tribal enterprise’s best interest to make sure that its benefit plan is using MLR when possible.
  • Since these regulations took effect on July 5, 2007, it is estimated that few are taking full advantage of the relatively new regulations, mostly due to the specialized administration required to properly process these complex claims.
  • How it works:
  • The Medicare-like payment rate will constitute payment in full to Medicare-participating hospitals that deliver services to American Indians and Alaska Natives referred through IHS-funded programs.
  • This includes all IHS-funded health care programs, whether operated by the IHS, tribes, tribal organizations, or Urban Indian organizations.
  • MLR applies to all levels of care: inpatient, outpatient, skilled nursing facility care and reduces contract health expenses for hospital services and enables Indian health programs to use the resulting savings to increase services to their beneficiaries.
mlr administration
MLR administration
  • At UMR, we are not only proficient in processing these claims, we have extensive Medicare repricing experience and currently process claims for several tribal entities. UMR is uniquely qualified to properly identify, reprice and process claims, regardless if the claim is from a tribal or non-tribal member ,and deliver those savings back to the tribal organization.
  • UMR’s role:
    • Provide member ID cards to all members with toll-free number to call for prior notification of services.
    • Conduct utilization review of inpatient services for medical necessity
    • Repriceeligible claims to Medicare-like rate
    • Process claims payments to provider at MLR, if applicable, or at the network discounted rate
    • Generate online plan management reports showing claims paid at MLR
mlr administration1
MLR administration
  • Plan holder’s role:
    • Authorized Tribal organization carrying out a CHS program. You must maintain CHS funding through the duration of the contract for services.
    • Prior review/authorization of any inpatient or outpatient facility services. You must verify whether the plan member is of American Indian descent, based on information provided through eligibility.
    • Transmit authorization of eligible claims. You must coordinate with Contract Health Services to obtain the necessary voucher/authorizations prior to any hospital services and cooperate with UMR to provide MLR authorization notices to providers.
    • Fund payment of eligible claims. You are responsible for funding claim payments paid by the plan using CHS funds or tribal dollars.
mlr claim workflow
MLR claim workflow

After a claim is submitted to UMR, and the member’s eligibility and tribal affiliation is verified (maintained in our system), we coordinate the process to reprice the claim at MLR. Contracted providers are not required to bill at MLR, however, they are required to accept payment at MLR if the facility is a Medicare participating hospital.

Claims for services not eligible for MLR are paid at network discounted rate.

Our online reporting tools allow you to identify claims paid at MLR and review information on benefit utilization, financial activities, network performance and enrollment.

tribal health care cost concerns
Tribal health care cost concerns
  • National statistics show Native American and Alaska Native adults are more likely to have chronic health conditions such as heart disease, diabetes and hypertension than those of other ethnic groups. 
  • They also show higher rates of smoking and lower utilization of health services than the general population.
  • UMR can help you develop a customized care management program that meets the particular health care needs of your member population. 
  • Based on in-depth analysis, we can help you identify those issues driving your plan costs and then tailor our approach to focus on certain behaviors: 
    • Encourage preventive care services
    • Educate members identified with costly medical conditions on ways to better manage their health
    • Target specific types of high-cost claims
    • Promote healthy lifestyle behaviors that reduce future health risk
  • Source: U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics
flexible care management
Flexible care management
  • UMR understands many of the care management services we provide are also available through tribal health center providers and facilities. We can customize our programs to maximize the use of your domestic facilities, clinicians, programs and initiatives, while interfacing with our care management services.
  • We offer two types of arrangementsfor coordinating our services with your internal resources:
    • Coordinated care management
    • Hybrid care management
coordinated and hybrid care management
Coordinated and hybrid care management
  • Coordinated care management - In this arrangement, UMR offers services that you can provide in-house. Rather than duplicate efforts, we can coordinate those services with your facilities and providers.
  • Hybrid care management - Under this more common arrangement, UMR will wrap its care management services around your internal resources.
customized wellness programs
Customized wellness programs
  • UMR can customize our health and wellness programs to your organizational culture, and work with you to incorporate your internal resources.
  • For instance, you can conduct your own clinical health risk assessment and biometric screenings and supply the data to UMR to identify members with current and future health risks. We then can help you develop incentive and reward programs that work best for the organization and your employees.
better decision making tools
Better decision making tools
  • UMR offers state-of-the-art reporting capabilities so you can measure just how effective your plan is and where your money is going. With UMR’s customized, on-demand reporting, you can leverage industry and national benchmarks to measure your plan’s trend.
  • UMR will provide you with in-depth plan analysis and recommendations to support continuous improvement and strategic decisions. We offer predictive technologies to support targeted, proactive health and wellness programs. And, our online resources are available 24/7, so you can access reports at your convenience.
  • We also provide your members with online tools to look up claims and benefits information, find providers, learn how to make the most of their health care dollars and improve their overall health and well-being.