TRICARE Global Remote Overseas Contract- Review

2007-2008

International SOS Medical DirectorTRICARE Pacific

23rd October 2008

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P a c i f i c Topics

• Who is International SOS (Intl.SOS)• TRICARE Global Remote Overseas

(TGRO)• Intl.SOS TRICARE Network• Collaborative Case Management• Quality Reviews• Challenges in Korea and Japan

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INTERNATIONAL SOSIntroduction to

Worldwide reachHuman touch

• Over 20 years experience• 5,600+ employees worldwide• Medical, security, aviation, and technical

specialists on staff– 1800 (32%) are medical professional– Multi-lingual staff with 70+ languages and

dialects spoken• Global Network of 51,000+ credentialed

providers• Experts in each center managing and auditing a

global network of medical correspondents and hospitals

• 7,650 clients worldwide – 83% Fortune 100

Experience and Expertise

Worldwide reachHuman touch

INTERNATIONAL SOS WORLDWIDE

Worldwide reachHuman touch

Services• Global Emergency

Assistance

• Remote Site Medical Services

• Health Care Management

• Security services

• International Clinics

• Specialized assistance services

• Online services

Worldwide reachHuman touch

Global Medical Assistance• 24-hour worldwide information and

assistance

• Pre-trip information and advice

• Doctor/hospital referrals

• Medical monitoring and case

management

• Emergency evacuations/repatriations

• Dispatch of doctors or specialists

• Hospital deposit guarantees

• Repatriation of mortal remains

• Integration with security crisis centers

Worldwide reachHuman touch

Global Medical Services:Remote Site Medical Services• Site surveys and audits• Development, operation and

management of medical facilities• Selection and training of medical staff• Procurement of medicines/supplies• First aid training• Continuing education for medical

professionals• Health assessments• Community health programs• Emergency and disaster planning• Occupational health programs

Worldwide reachHuman touch

International Clinics• 28 clinics worldwide

• International standards of care in developing areas

• High level of family practice medicine and emergency care

• International health care professionals

• Well-trained local medical staff

• 24-hr emergency assistance

• In-house laboratory/diagnostics/pharmacy

Worldwide reachHuman touch

Alarm Centers• 26 worldwide

• Open 24 hours a day, everyday

• Multi-lingual operations coordinators

• Full-time doctors, nurses and pharmacists

• Global network of preferred medical, legal and security providers

• Over 70 languages and dialects spoken

• Online airline and hotel reservation systems

Worldwide reachHuman touch

Aviation Resources• Ten dedicated air ambulances

strategically located around the globe

• State-of-the art intensive care transport system

• 24/7/365 access to private and commercial aircraft

• In-house physicians trained in aeromedicine

• Global aviation department to secure flight paths and clearances

• Worldwide network of escort doctors and nurses

Worldwide reachHuman touch

Options for transport are varied…

Worldwide reachHuman touch

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COMMERCIAL AIRCOMMERCIAL AIR

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TRICARE GLOBAL REMOTE OVERSEAS (TGRO)

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• Cashless / Claimless Services to TGRO Beneficiaries

• Case Management – Quality of Care• Global Consistency of Approach in Delivering

Healthcare Services • SOS TRICARE Credentialed Network

• Outpatient, Inpatient, and Specialist Care• 24 x 7 Urgent/Emergent Care Capacities

• Medical Transports• Governed by TRICARE Policies

TGRO AD/ADFM Beneficiary Services

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Coverage under TGRO

Routine, Urgent and Emergent Care for Active Duty (AD) and Active Duty Family Members (ADFM) permanently stationed in a TGRO Location.

Urgent and Emergent Care for Active Duty TDY/TAD, Reservist, On Leave, Liberty, Navy/Marine/Coast Guard Deployed.

Urgent and Emergent Care for AD traveling in MTF Countries (NEW)

Emergent Care for PRIME ADFM traveling OCONUS (NEW)

TRICARE Beneficiaries Excluded from TGRO

TRICARE Retirees / TRICARE For Life

TRICARE Standard

Direct Care

Coverage under TGRO

Routine, Urgent and Emergent Care for Active Duty (AD) and Active Duty Family Members (ADFM) permanently stationed in a TGRO Location.

Urgent and Emergent Care for Active Duty TDY/TAD, Reservist, On Leave, Liberty, Navy/Marine/Coast Guard Deployed.

Urgent and Emergent Care for AD traveling in MTF Countries (NEW)

Emergent Care for PRIME ADFM traveling OCONUS (NEW)

TRICARE Beneficiaries Excluded from TGRO

TRICARE Retirees / TRICARE For Life

TRICARE Standard

Direct Care

TRICARE Global Remote Overseas

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Intl.SOS TRICARE History

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TRICARE Global Remote Overseas

Credentialed Network• SOS TRICARE Credentialed Network• Primary and specialist care• Monitoring and quality control• Distributed Provider Relationship

Management• Leverages utilization by other Intl.SOS

Corporate, Government, and Insurance clients

Beneficiaries• Enrolled and TDY/TAD/Deployed• 24x7 medical advice from Intl.SOS

doctors/nurses

Single Service Standard Across Regions• Europe• Latin America• Asia Pacific

Claims Processing• ICD/CPT Standard Coding• Translation of International claims• HIPAA Compliance• International SOS Claims Audits

Case Management / Medical Oversight

• Management of Routine and Urgent Care consistent with TRICARE Healthcare Policies

• Case management system that provides a longitudinal record of interactions with beneficiary

• Referral Management into MTFs and private sector

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INTL.SOS TRICARE NETWORK

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Network Management staff located in SOS Alarm Centers globally

Manages an extensive world-wide service provider network

Ensures providers adhere to SOS quality standards through regular site visits, audits, and credential verification

Provides customized network solutions in accordance with client objectives

SPIN : A proprietary worldwide information system to classify and manage providers

SPIN: Service Provider Information Network

International SOS Global Assistance Network

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TRICARE Global Remote Overseas Locations

145 Countries240Locations

Multiple Locations

Intl SOS TRICARE Regional Center

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P a c i f i cThe Tricare Network

Tertiary

Providers

SOS TRICARESecondary Providers

SOS TRICARECredentialed

Network

In-Network Providers

All documents gathered

Site survey successful

PSV on Education

In-Network Providers

All documents gathered

Site survey successful

PSV on Education

Partial Documentation

Credentialing in Progress

Credit Terms in Place

Partial Documentation

Credentialing in Progress

Credit Terms in Place

Known to SOS

Credit terms in place

Satisfactory Performance

Known to SOS

Credit terms in place

Satisfactory Performance

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Network Challenges

• Clear distinction between the fully credentialed Intl. SOS Tricare network & the outer rings

• Monitoring healthcare in host nation facilities• Recognizing the ‘gulf’ between East-West

medical training & practice• Host nation healthcare vs MTF’s• Low threshold for medical transport

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Managing a Global Network

Network is determined by many factors

The network is managed through continuous monitoring of credentials, customer feedback, concurrent case management, site visits

Selecting the Most Appropriate Providers

Sizing the Network to manage quality and utilization

Knowing and Communicating the Limitations of the Network Country/Location Specific

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TGRO Credential Requirements

Confirmed current Medical/Dental registration Copy of a current C.V. with 5 year history Primary source verification of Medical/Dental

training at a recognized facility Copy of signed service provider agreement Copy of site visit report Confirmation of Malpractice insurance, where

applicable

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P a c i f i cCredentialing Process

Other Credentialing Aspects English speaking Accepts SOS GOPs or signed

agreement US Board Certification Leveraging of hospital

credentialing procedures Experience with International

Patients

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SOS TRICARE Network Maintenance Activities

Provider Data Maintenance Provider information entered in SPIN Immediately available to Operations WPS Provider ID Banking details / Preferred payment methods Hard copy files as back-up

Provider Communication Operations, POC and Member Feedback

Direct Communication or Beneficiary Satisfaction Surveys

Investigation and Resolution of Provider/Beneficiary Issues

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P a c i f i c Building Relationships

• Relationship building with host nation providers targeted at all levels Physician, Nursing, Reception, Cashier

• Guarantees of Payment (GOP) • A network is only as good as the last time it was used

and paid.• Three Intl.SOS elements involved

1. Global Area Network personnel ( agreement )2. Multi lingual coordinators ( send the GOP)3. Accounts & billing staff ( receive/pay invoices)

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COLLABORATIVE CASE MANAGEMENT

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P a c i f i cCase Management services

• Based in International SOS Alarm Centers with a dedicated TRICARE team

• First contact Coordinators and Nurses

• Supported by other SOS Medical staff and International SOS Centers

• 24/7 service including verification of eligibility through GIQD

• Direct access to services in over 70 languages

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Medical Oversight The Notification Of Case ( NOC)

• A requirement to advise to TAO-P Medical Director, as part of medical oversight & monitoring of care of

-all admissions -hospitalizations extending over a 1 week

-readmission for same diagnosis within 30 days

-4 x spec. visits < month for same diagnosis

- outpatient costs >$2000 /month - limits on Mental Health/Physical Therapy

visits

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QUALITY MANAGEMENT

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P a c i f i c Quality Management

• Ensuring an International Standard of Care• TRICARE Quality Plan

Quality Issue Review Process Grievances, Potential Quality Incidents (PQI), and Quality

Incident (QI) Escalation process within Intl.SOS Escalation to TRICARE Area Office on all Quality Incidents

Network Credentialing Requirements TRICARE Bi-Annual Audits Beneficiary and TRICARE POC Surveys

•

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P a c i f i cQuality Management (cont)

Network

• TRICARE Provider Credentialing

• Provider agreements

• Site visits

• Right Sizing

• Beneficiary demographics

Case Management

• Concurrent Case Management

• Longitudinal View

• Medical Oversight

• TAO Escalation

• CAD Oversight

• Review of medical reports and discharge summaries

Quality

• Case Reviews

• TRICARE Bi-Annual Audits

• Beneficiary Surveys

• Communication with other Govt Agencies (e.g. Health Unit)

FEEDBACK LOOP

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Beneficiary Surveys Tools

Automated delivery from Intl SOS Case Management System

Pushed to the Beneficiary through the email & Web

Surveys Results Collected by Third Party – KeySurvey

Beneficiary Survey Reports are deliverable every (6) months to TMA

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CHALLENGES IN KOREA & JAPAN

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Big Challenges require great effort and coordination…

Healthcare in Japan & Korea

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Healthcare in Japan & Korea

• National Health Insurance• Hospitals & clinics are national health system

centric• Limited English language capability• Private organizations have limited influence• ER’s are crowded & capability can be limited• Public ambulances move only within their

district• Ambulances have limited capability• Reluctance to accept guarantees of payment

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• A recommendation for host nation in-patient care for non urgent surgery depends upon a number of factors;

• Standard of care available?• Requirements of the Services

Fitness for Duty Length of absence from duty and impact on the

unit Need for & duration of Rehab VA issues

• Financial estimates• Comfort level of the patient

Healthcare in Host NationsJapan & Korea

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P a c i f i cIntl.SOS Example

• International SOS SeoulEstablished in 1989Leading provider of medical and security

assistance in the region Business and Leisure Travelers Corporate Expatriate communities in South

KoreaSeoul receives over 4 Million tourists per

year 1.2 million are covered under Intl.SOS

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P a c i f i cIntl.SOS South Korea

• Volumes drive Intl.SOS capabilities to engage providers. Map shows were

Intl.SOS have agreements and financial arrangements for healthcare services

• Intl.SOS Local Operations Staff and Medical team are crucial in obtaining the appropriate and International Standard of care

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QUESTIONS?