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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
In-network Claims:
  • PHCS
  • Multi-plan
  • Three Rivers
  • InterPlan
  • Beech Street

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
In-network Claims:
  • PHCS
  • Multi-plan
  • Three Rivers
  • InterPlan
  • Beech Street

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
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

slide12
*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 PAL is an advocacy service available to employees and their covered family members when faced with:
  • Chronic health conditions
  • Emergencies
  • Major surgeries
  • High-risk critical illnesses
  • Catastrophic health events

PATIENT PALTM

patient pal care continuum
Well Patient Entry
  • 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

Electronic Medical Record (EMR)

london medical management contingency fee
Health Claim Cost Reduction:
  • 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
  • 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
  • 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.
summary
SUMMARY
  • Health Claim Cost Containment Solutions
  • Unique combination of Health Claim Negotiations with Patient PALTM advocacy services
next steps
NEXT STEPS
  • 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

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

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

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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