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TEAM HCRS
Team HCRSValue
Proposition
September 1, 2011
2
Overview
About our firms Why us? Our approach Questions and feedback
3
About
HCRS
Medical Coding, Auditing and Payment Integrity Specialists
More than 150 certified medical professionals on staff
Operating at 70 sites in over 40 states In business since 1998 Woman- and Minority-owned business
A Major Provider of Health Information Management Services
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HCRS
Clients
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About
TC3
Since 2000, providing comprehensive claims cost management services to diverse group of 70+ payer clients nationwide, including health plans, Managed Medicaid Plans, Medicare Advantage Plans, TPA’s, and Taft Hartley Funds
Experienced team of multidisciplinary professional staff including: Special Investigators specializing in complex health care fraud
investigations Managed care professionals experienced in both commercial and
government programs Registered Nurses Certified coding professionals (RHIA, RHIT, CCS, CCSP, CPC, CPC-H)
Able to manage large claim volume. Currently processing over 75 million claims annually with a claims value of over $55 billion through its fraud, waste, abuse and other payment integrity programs
Expert Payment Integrity Services
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Single Entry Point – High Impact Savings
Paid Claims
Discovery
Validation
Recovery
Provider MatchClaim DiagnosticsClaim AnalyticsClinical Code EditingDuplicate Detection
Analysis of Automated ResultsComplex/Medical Record Reviews
Letters to ProvidersFollow-up Calls to ProvidersClient PortalCustomer Service Center
About
TC3
0.5%-3% Savings
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Overview
About our firms Why us? Our approach Questions and feedback
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Our
Value
Current Medicaid audits, including Louisiana High ROI audits Payment Integrity services to more than 70
payers Over 65 successful contingency contracts Leading-edge technology integrated with
experienced staff Assertive, professional recovery efforts Prevention as well as recovery services
Team HCRS Combined Capabilities
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Our
Value
MIC audit subcontractor for nineteen states and three territories (HCRS), including collaborative field audits with the State of Louisiana focusing on hospitals and long-term care facilities
Special state-level inpatient audits for Maryland and Virginia (HCRS)
Subcontractor for Overpayment Identification for the State of New Jersey (TC³)
Focused audits related to transportation and translator services for Managed Medicaid Plan in MN (TC³)
Current Medicaid Audits
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Our
Value
Louisiana Learning to Date
0
200
400
600
800
1000
1200
1400
Samples
% Audit Discrepancies By Provider Type(n Samples >100)
# Samples
# Discrepant 100%
85%
100%
80% 68%
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Our
Value
Louisiana Learning to Date
$2,586
$214 $371$84
$346
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Average Value of Overpayments by Provider Type (n Samples >100)
Average Overpayment
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Our
Value
High ROI for Audits
HCRS MIC results have exceeded $8 in incorrect payments for every $1 spent on audit– High-quality data analysis results in greater
return for the type of overpayments that are the focus of each audit
– Highly-experienced auditors identify more additional errors beyond the primary focus of the review
TC³ averages 5:1 ROI TC³ achieves range of .5%-3% reduction
in paid medical claims cost
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Our
Value
Payment Integrity Services for More Than 70 Payers- Tangible Results
Prevention – Cost avoidance through pre-payment integration 0.5-3% of paid medical cost reduction
0
50
100
150
200
250
300
11 13 25 28 30 45 48 60 62 80
Savings ($Ks)
# of Members (Ks)
Monthly Savings
Recovery – Customized pursuit of VALID overpayments leads to successful recoveries and few appeals
Feedback – Identify and fix root causes to avoid future overpayments
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Our
Value
Proven Results“HCRS is a group of professionals who really know their business. They’re reliable, easy to work with, and they deliver. We’ve been increasing the amount of work we do with them, and we see them as a long-time partner as we expand our presence in Medicaid payment integrity.”Vice-President, Business Development, OptumInsight (formerly known as Ingenix)
“HCRS’ performance has not only been superior, but timely…At AETC we are consistently asked what has generated such success, I can honestly say the contract partnership with HCRS is at the center of our success.” Chief, Medical Resource & Programming Branch, Headquarters, Air Education and Training Command, United States Air Force
“We wanted to save money for our groups and members. All goals have been surpassed on all levels with TC³. The company helped us streamline our internal processes and reduce administrative work by integrating with external data sources. We are confident we’ve retained a highly-respected long term partner for more efficiently controlling costs.”Client for 7+ years
“Our experience with TC3 has been excellent. Not only is their technology state of the art, but their commitment to customer service is outstanding.” Vice President-Operations, The Loomis Company
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Our
Value
Highly Experienced and Successful Contingency Contractor
Execution of successful contingency fee based relationships for over 8 years
Goals aligned – Accurate, sustainable findings, recovery process that maintains positive provider relationships
Conservative approach - TC³ is sensitive to the challenges faced by providers in today’s healthcare climate. The focus is not on penalizing providers.
Mature technology and processes in place to support contingency fee contracts
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Our
Value
Integrated Approach – Technology and Experienced Staff Discovery – Technology to identify overpayments and suspect
claims• Provider Match Program – Watch Lists• Claim Analytics – Algorithm based technology powered by
DataProbe®
• Claim Diagnostics - Rules-based technology powered by TC³’s TruClaim engine
• Code Edit Compliance and Duplicate Detection Triage, Validation and Recovery
• Post-payment review – Systematic validation of automated reviews. Complex reviews performed by qualified staff
• Recovery process customized to client specifications• Pre-payment option – Pay/Deny results within 24 hours.
Complex reviews available.
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Findings - Examples
Non-Emergency Transportation Identified 57,009 claims billed with a transportation code with no
corresponding medical claim (including dental/chiropractic encounter claims and pharmacy/PBM claims) for the same member and same date of service. The corresponding dollars paid for these transportation claims was $3,025,502.86.
Translator Services Review of the data indicated that there were 24,935 claims
submitted for interpreter services for dates on which no other service was apparently provided. The dollars paid for these claims was $1,315,676.43.
Personal Care Attendant Services There were no medical claims found for many members receiving
daily PCA services. PCA services provided while the member was inpatient totaled a paid claim amount of $24,668.97. The number of units billed for single dates of service appears excessive. Daily services were billed by a provider whose address is a 1-2 hour drive from the home of the member (potential for services not rendered.)
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Our
Value
Assertive, Professional Collections
Customized process designed by the State of Louisiana (amount of time, number of letters, and phone effort)
All payments can be directed back to any source that the State chooses.
The State of Louisiana has access to all phases of effort through a Client portal established in your name.
All phone conversations are recorded for quality assurance and are available for review by the State.
Client has total control over any account in the system and can withdraw, suspend, or cancel our efforts at any time.
Fully HIPAA compliant All services are entirely based in the United States and
performed by personnel with specific skills in health care related recovery
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Our
Value
An Option: Prevention Capability and Experience
Pre-payment solution includes daily claim scrubbing to identify potential overpayments
Utilizes same components and technology as post-payment solution
Identify root causes that contribute to overpayments and provide feedback to address these issues.
Why Pre-payment? Cost avoidance in real time, deterrent effect, individual claim denials more acceptable than mass recoveries
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Overview
About our firms Why us? Our approach Questions and feedback
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Our
Approach
Approach Overview
Data Mining/Analysis
Record Request & Handling
Record Review
Collections
• Multilayered approach blends technology and human expertise
• Achieve and validate focus through traditional edits, proprietary diagnostics/analytics + your input
• Local call center and scanning staff – we train in customer service and provider relations
• We are experienced in f/u, scanning in Louisiana (Audit MIC subcontract)
• Initially, our experienced coding and pharmacy auditors (later, local hires)
• RN auditors for medical necessity review• Medical necessity decision by physician
• Continuous consultation with state on individual cases
• Appeal process IAW law and regulations• Sensitive, prudent persistence
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Our
Approach
Process Overview
Run through customized screening protocol
Claims data file
Validate, report
potential over/under-payments to
MVA/PIS
MVA/PIS guidance
Review?
· Data mining using TruClaim (proprietary) and Data Probe (Thomson Reuters)
· Suspect provider data bases
· MVA/PIS targets· 100+ Proprietary and
traditional algorithms· Code edit and duplicate
detection technology· Validation studies · Continuing updates
Collect /refund?
Yes
No
Collection or refund IAW Louisiana law/regs
Feedback to process
Yes
CORE/TruClaim Case Tracker
Synthesize experience,
identify trends for study, and
update screening protocol
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Our
Approach
Implementation Plan
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Overview
About our firms Why us? Our approach Questions and feedback
