PayerFusion Operational Overview


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Take a deeper look at the operations of PayerFusion. Learn about the services we provide, how we can help better the healthcare industry, and the benefits of partnering with us.

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PayerFusion Operational Overview

  1. 1. May 21, 2013 A six sigma-total quality management company. The next generation of cost containment and claims management technology. Operational Overview 2013
  2. 2. We use a combination of HIPPA Compliant technologies and services to provide the next generation of claims management solutions. • Privately held company with corporate offices in Miami. • Proprietary provider network and a zero balance billing guarantee. • Technology that supports 3rd party administrators, payers and providers. • State-of-the-art Internet-based software for payer processing. • Flexibility to enable payer-specific customizations. • Experts in billing guidelines and coding standards, network development and payment execution and receivables. OVERVIEW
  3. 3. Our mission is to assist insurance companies, self-insured multi-national companies and providers in settling claims in a fair and timely manner. • Promoting our clients’ branding and awareness in the International and Domestic marketplace. • Reducing average claim payment cycles with established financial commitments and guidelines. • Reducing administrative expenditures of collection efforts by providers and unnecessary parties that delay payments and provide no patient steerage. • Providing superior customer service to all stakeholders. • Maintaining a technological edge through service delivery. • Securing the elimination of silent PPO, simplifying administration of services and facilitating an increase in patient base. • Keeping abreast of the transient regulatory changes of the US payer marketplace. OUR MISSION
  4. 4. OUR SERVICES & THE INDUSTRY • PayerFusion represents a cost effective solution for the Provider with effective and consistent cash flow matrixes, designed and analyzed to each payer in each geographic area of the world or point of origin. • Our process focuses on fair equitable payment based on time, the value of money and the AM Best classes of payers (risk assessment). • Times are changing in the U.S. healthcare market, most solution offers represent “more of the same”. • PayerFusion moves away from the traditional PPO discount and customizes a successful structure for Provider and Payer.
  5. 5. PayerFusion is dedicated to assist international payers in finding effective solutions to support policy compliance and administration. • Provide guidance and forward thinking in structuring policy and claims models for non-USA companies and domestic companies • Advising on the best practices for preserving premium ratios and competitive advantage. • Maintain international payer brand recognition while keeping claims costs consistent with USA domestic companies. WHY PAYERFUSION?
  6. 6. • Unparalleled market experience. • Seasoned, well-integrated and collaborative management team. • Forward thinking approach connecting our knowledge and vision for healthcare reform to proactive policies and procedures. • A commitment to excellence. • A Six Sigma approach to continuous quality improvement. • Technology solutions to provide you with complete transparency, access and information to help you manage your portfolio. • Bottom line results: We help you control your cost per claim and effectively deal with healthcare inflation. WHY PAYERFUSION?
  7. 7. PayerFusion Holdings LLC PayFuseNet LLC • The legal structure of PayerFusion ® has existed since 2009. Florida Limited Liability Company. • Obtained licenses in all State and passed the strict requirements of the insurance commissioners in each and every State, this is an important seal of approval of the authorities of integrity. • No legal pending matters in any State or with any entity. • Our principals and management have been in the industry for more than 30 years. • Many key management staff have worked together before which helps foster a strong team with industry knowledge and a commitment to excellence. LEGAL STRUCTURE
  8. 8. LEADERS IN OUR FIELD • Founder and CEO of HAA Preferred Partners, LLC, a U.S. based preferred provider organization and third party administrator (sold 2007). • Grew company from $0 to $12MM in revenue and became recognized as top quality provider operating in an ISO certified environment transacted over 150 million dollars in claims, company growth in excess of 25% annually- sold 2007. • Former Director with Blue Cross and Blue Shield of Florida and the Federal Medicare. • Former Executive at Mount Sinai Medical Center, Miami Beach, Florida, a non- profit, 600 + plus bed teaching hospital of national recognition. • Graduate degrees in Healthcare Administration and Public Health. • Member of President Bill Clinton’s healthcare reform task force. • Recipient of the Woman of the Year Award by President George W Bush and the Republican Party in 2005. • Participant in President Barack Obama’s healthcare reform support task force. Griselle Chernys President & CEO
  10. 10. Claims Operations Case Management & Utilization* Network Management Provider Relationships Client Service Key Business Activities *Optional Service per Client request BUSINESS PROCESS MODEL Support Activities Web Enabled Technologies (Web Portal) Reporting and Decision Support Services Technology Department
  11. 11. OUR SERVICES Medical Case Management Network Design & Support Technology Solutions/Support & Informatics Travel Assistance Services Plan/Policy Administration (TPA) Concierge Medical Services Air Ambulance & Medical Escort Provider Reimbursement Custom Reporting Call-Center Services
  12. 12. SERVICE OPTIONS OPTION1:FULLSERVICE OPTION2:CLAIMMANAGEMENTSERVICES OPTION3:COSTREPRICINGSERVICES Our complete service option provides our clients with 24/7 access to call center services that are customized to your specific needs and requirements. We will customize other processes and SLA’s to meet your needs and standards. • Care Setting • Care Assistance Services • Claims Management • Case Management & Utilization Review • Utilization of PayFuseNet Provider Network • Bill Review & Auditing • Customer & Client Services With this option, PayerFusion handles only the health policy portion of the travel policy. This option allows the client to take advantage of PayerFusion’s expertise in medical claims management, utilization review, and our comprehensive networks and savings. • Claims Management • Case Management & Utilization Review • Utilization of PayFuseNet Provider Network • Incident management This option is for clients who perform their own call center functions, case management and claims review in-house. Approved claims are submitted to PayerFusion for re-pricing via our networks. We also administer claims in the Caribbean, Canada, Central and South America and other parts of the world. With this option, the client may choose to execute the payments or PayerFusion can execute and adjudicate the claim. • Re-pricing for US & International Claims • Provider Reimbursement (optional)
  13. 13. • Cost Plus – Claims Reduction • Network Affiliates • Claim Analysis and Validation • Fraud Detection • Benefits Verification and Coordination • Claims Processing & Provider Payment • Secured/Firewall Environment • Customized PPay (Explanation of Benefits) • Customized Batch Processing • Zero Balance Confirmation Claims Management CapabilitiesCLAIMS MANAGEMENT
  14. 14. Case Pre-Settlement • The process of pre-settlement is modeled according to our Cost Plus methodology. It uses the estimated charges (reserves) calculated by our Medical Case department and the benchmark data from the government sources. • There are multiple ways to pre-arrange payment settlement by packaging conditions. For example: (1) cardiac, (2) labor and delivery, (3) orthopedic surgery, (4) solid organ transplant. • Case pre-settlement guarantees our ability to obtain a fair price for quality services and it ensures there is no over-utilization. • Handling an entire episode of care allows us to expedite the claims processing and payment to the provider, which further reduces the cost per claim and recognizes the client as a good payer. CLAIMS MANAGEMENT
  15. 15. Claim Analysis & Validation • This function consists in reviewing each claim for billing discrepancies in the structure of the case, duplicate charges, inaccurate coding. It is based on government established billing practice codes by the AMA (American Medical Association) and CCI (Correct Coding Initiative) • Our ability to maximize the benefit of fully validating a claim requires that we have a complete set of claims related to an episode of care. For example, multiple charges for the same service could be submitted on separate claims and we may only receive one of them. CLAIMS MANAGEMENT
  16. 16. Fraud Detection Fraud Detection Criteria • Excessive billing amounts • Higher Costs per patient • Excessive number of patients per doctor • Increased number of tests per patient • Abnormal distance between treatment location and patient home. • Higher rates of prescriptions for certain drugs 1. Billing for services not provided or needed 2. Multiple billing for services A. Administering tests not medically necessary B. Administering more expensive tests Examples of Fraud: Examples of Abuse: CLAIMS MANAGEMENT 2 1 A B
  17. 17. OUR REIMBURSEMENT METHODOLOGY Our unique approach to claims management enables our clients to reduce the cost per claim. It is supported by national data reported by US federal agencies. Our methodology allows providers reimbursement, which affords them a fair profit to maintain quality and a competitive standard of care.
  18. 18. • Our clients obtain the best pricing available because we have all key financial elements needed to develop a reimbursement model for our direct contracts: the retail price, the actual cost, and an understanding of how each provider needs to offset losses from its Medicare patients. • Our expertise and experience on all sides of the healthcare business enable us to understand the needs of each stakeholder in the healthcare equation. It is an invaluable advantage in negotiating effectively and maintaining long-term relationships. • We speak the language of both the provider and the payer supported with empirical data, which allows us to produce sustainable results built on effective but fair negotiations with healthcare providers. COSTPLUS REIMBURSEMENT ADVANTAGE Detailed data on 90% of all hospitals Public Data HCRIS Files: Hospital Cost Reports State All-Payer Files: Commercial Payers, Medicare, Medicaid MedPar Files: All Medicare discharges SAF Outpatient Files: Institutional Outpatient claims OPPS Files: Outpatient claims Millions of discharges Approximately 75% of all discharges nationally >140 million outpatient occurrence Data refreshed monthly (most recently 12 months, inflation, Wage Index factors normalize the data)
  19. 19. •Urban •Rural Hospital Location •Teaching •Non-teaching Facility Type • 1 – 150 • 151 – 300 • 300+ Bedsize Category National Discharge Database We use our proprietary methodology to assess each claim amount based on actual benchmark information stratified by the following categories: • Each inpatient claim is compared to a benchmark group of similar clinical cases, in “like” hospitals, over the most recently available 12 months. • Wage Index Adjusted as assigned by CMS.
  20. 20. The percentage difference between the highest and the lowest cost for the same service is on the average only 18%, while the measure of dispersion for the charges is much higher – on the average, 44%. BENCHMARK ANALYSIS OF COSTS & CHARGES
  21. 21. Medical Services Cost Charges Major joint replacement or reattachment of lower extremity 11% 88.35% Other Infectious & Parasitic Diagnoses 49% 69.69% Urinary Stones w/o ESW Lithotripsy w/o MCC 27% 43.56% Intracranial hemorrhage or cerebral infarction w cc 19% 46.03% Cardiac Valve & Oth maj cardiothoracic proc w card cath w cc 6% 9.01% Nutritional & Misc metabolic disorders age >17 w CC 20% 62.07% Simple pneumonia & pleurisy w cc 11% 19.33% Lower Extreme & humer pro except hip, foot, femur 23% 51.75% Heart Failure & Shock w cc 36% 66.40% Permanent Cardiac pacemaker implant w/o cc/mcc 9% 30.06% Appendectomy w/o complicated principal diag w/o cc/mcc 15% 28.23% Major joint replacement or reattachment of lower extremity w/o mcc 10% 46.06% Respiratory System diagnosis with venlator support < 96 hours 11% 45.94% Septicemia w/o mv 96 + hours age >17 12% 40.61% Appendectomy w/o complicated prinicipal diag w cc 3% 20.55% Perc cardiovasc proc w/o coronary artery stent w/o mcc 19% 43.26% Peripheral vascular disorders w cc 11% 23.57% Coagulation disorders 25% 57.52% Percutaneous cardiovascular proc w drug-eluting stent w/o maj cv 6% 9.45% Dysequilibrium 20% 98.27% Major small & large bowel procedures w cc 20% 86.66% Cellulitis w mcc 8% 31.67% Other musculoskelet sys & conn tss o.r. proc w/o 27% 69.24% Appendectomy w/o complicated principal diag w/o cc/mcc 18% 45.51% Periph/cranial nerve & other nerv syst proc w mcc 35% 57.01% Respiratory system diagnosis with ventilator support < 96 hours 11% 15.25% Urinary stones w/o esw lithotripsy w/o mcc 12% 20.01% Perc cardiovasc proc w drug-eluting stent 7% 8.37% Otitis media & URI age 0-17 23% 22.30% Extraocular procedures except orbit 29% 56.12% Hip & femur procedures except major joint w/o 26% 19.89% Rehabilitation w/o cc/mcc 34% 45.40% Intracranial Hemorrage or Cerebral Infarction W CC 17% 73.21% 18% 44% BENCHMARK ANALYSIS OF COSTS & CHARGES % difference between the highest and lowest costs & retail charges
  22. 22. Model Components Facility A Facility B Owner Private, Not for Profit Private, Not for Profit Teaching Status Teaching Non-Teaching Bed Size Large Small Region Northeast Midwest Location Metropolitan Non- Metropolitan Actual Charges $9,202 $27,006 Actual LOS 1 day 1 day Benchmark Average Charges $21,313 $19,420 Benchmark Average Cost $6,643 $7,212 Benchmark Average LOS 1.52 1.54 Facility Charge v. Benchmark -34% 118% Benchmark % Mark Up from Cost 221% 170% Facility estimated % Mark Up 111% 478% Baseline Reduction at Benchmark -52.64 53.23% Actual Reimbursement $6,000.00 $14,000 % Mark Up from Cost 37% 199% % Reduction 35% 48% • Facility A: Mark-up from cost at 111%, which is below the benchmark average of 221%. • Facility B: Mark-up from cost for the same service is 478%, significantly higher than its peers benchmarked at 170%. • To maximize value to payer and achieve fair pricing for provider, claims were repriced at a reduction of 35% and 48%, respectively, from retail charges. $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 Actual Charges Benchmark Charges Benchmark Cost Appendectomy w/o complicated principal diag w/o cc/mcc (DRG 343) Facility A Facility B COMPARATIVE ANALYSIS
  23. 23. OUR REIMBURSEMENT METHODOLOGY DRG: 149 - Disequilibrium 729% 201% 0% 200% 400% 600% 800% Facility Mark up from Cost Benchmark Mark up from Cost Cost of Care Analysis Measures Actual Results Actual Charges $15,834 Cost of Care $1,910 % Mark-up from Cost 729% Payment to Provider $6,500 % Mark-up from Cost 240% Gross Reduction $9,334 % Gross Reduction 59% PF Access Fee $1,680 Net Cost of Claim $8,180 Net Reduction $7,654 Net % Reduction of Charges 48% Cost-Plus Results – Example 1
  24. 24. OUR REIMBURSEMENT METHODOLOGY Cost-Plus Results – Example 2 DRG: 343 - Appendectomy w/o complications 218% 196% 185% 190% 195% 200% 205% 210% 215% 220% Facility Mark up from Cost Benchmark Mark up from Cost Cost of Care Analysis Measures Actual Results Actual Charges $27,006 Cost of Care $4,688 % Mark-up from Cost 476% Payment to Provider $14,000 % Mark-up from Cost 199% Gross Reduction $13,006 % Gross Reduction 48% PF Access Fee $2,081 Net Cost of Claim $16,081 Net Reduction $10,925 Net % Reduction of Charges 40%
  25. 25. OUR REIMBURSEMENT METHODOLOGY Cost-Plus Results – Example 3 DRG: 330 – Major sm & lrg bowel procedures w/ cc 218% 196% 185% 190% 195% 200% 205% 210% 215% 220% Facility Mark up from Cost Benchmark Mark up from Cost Cost of Care Analysis 31% 21%9% 39% Cost Plus Results Cost of Care Plus Mark-up PayerFusion Fees Net Reduction Measures Actual Results Actual Charges $76,618 Cost of Care $24,130 % Mark-up from Cost 218% Payment to Provider $40,000 % Mark-up from Cost 66% Gross Reduction $36,618 % Gross Reduction 48% PF Access Fee $6,591 Net Cost of Claim $46,591 Net Reduction $30,027 Net % Reduction of Charges 39%
  26. 26. OUR REIMBURSEMENT METHODOLOGY Cost-Plus Results – Example 4 DRG: 599 – Malignant breast disorders w/o cc/mcc 476% 170% 0% 100% 200% 300% 400% 500% Facility Mark up from Cost Benchmark Mark up from Cost Cost of Care Analysis 21% 45% 5% 29% Cost Plus Results Cost of Care Plus Mark-up PayerFusion Fees Net Reduction Measures Actual Results Actual Charges $7,656 Cost of Care $1,582 % Mark-up from Cost 384% Payment to Provider $5,000 % Mark-up from Cost 216% Gross Reduction $2,656 % Gross Reduction 35% PF Access Fee $425 Net Cost of Claim $5,425 Net Reduction $2,231 Net % Reduction of Charges 29%
  27. 27. Key Metrics July, 2012 YTD Total Gross Charges Closed $20,200,478 Total Actual Reimbursement $11,110,262 Gross Reduction Amount $9,090,216 Gross Reduction % 45% % Reduction Due to Claim Review 3.4% % Reduction Due to Provider Contract 41.6% PayerFusion Fees at 20%* $1,818,043 Net Reduction after PayerFusion Fees $7,272,173 Net Reduction % after PayerFusion Fees 36% Claims Cost Number of Claims Priced 8,782 Average Gross Cost per Claim $2,300 Average Cost after reduction $1,265 Average Net Cost after PayerFusion Fees $1,472 Other Statistics: Total Number of Claims Closed 8,782 Average Claim Age (DOS) upon receipt 56 Average Turnaround days 18 Claim Status Gross Charges % of Total Total Count % of Total Closed $20,200,478 80% 8,782 76% In Process $3,282,578 13% 2,196 19% Returned $505,012 2% 116 1% Pending Authorization $757,518 3% 231 2% Duplicate $505,012 2% 231 2% Total $25,250,598 100% 11,555 100% 80% 13% 2% 3% 2% % of Total Gross Charges by Status As of July, 2012 YTD Closed In Process Returned Pending Authorization Duplicate SAMPLE CLAIMS SCORECARD
  28. 28. • Daily Ppay Batch report • Case Update and Reserve Information • Monthly invoice • Zero Balance Report • Monthly Dashboard • Quarterly Performance Dashboard • Productivity reports by Agent • Claims Analyses • Comparative Analyses • Benchmark Cost Analyses • Claims Status Reports • Inventory Claims Management Reporting • Data Analysis and modeling Customized Client Reporting Internal Reporting & Controls REPORTING & PROCESS OUTPUTS
  29. 29. $0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 1Q 2Q 3Q Total Charges Closed 15% 20% 25% 30% 35% 40% 45% 1Q 2Q 3Q Average % Reduction per Quarter 0 10 20 Avg Qrt Target 15 20 Average Turnaround days to process claims SAMPLE MEASURABLES
  30. 30. No Process Outcomes Measure Metric Target 1 Acknowledged receipt of new case Responsiveness Turnaround time 24 hours from receipt of case 2 Delivery of estimated reserves for each episode of care Timeliness Turnaround time 48 hours from receipt of case 3 Maintaining accurate reserves for episode of care Accuracy % of Actual Cost 95% 4 Follow-up on each case Effectiveness % of time cases are followed up every 48 hours 99% 5 Reduction of claims Financial Efficiency Average % Gross Reduction 43% 6 Claim processing and release of Ppay Process Efficiency Average turnaround (from receipt of claim to release of Ppay) 20 business days 7 Confirmed zero balance on each patient account Effectiveness % of closed accounts at zero balance 100% KEY QUALITY METRICS
  31. 31. PayerFusion is a technology driven company providing clients with online access for monitoring the entire claims cycle, an online provider search, advanced call-center technology and a user-friendly mobile app. • Claims Portal to review all claims statuses and claims results and ageing. • On line provider search branded with your company name and logo featuring interactive driving directions and Google maps integration in multiple languages. • Dedicated phone numbers and toll free numbers when applicable answered in the Client’s brand if required. • Mobile application for the provider search with geo location feature to locate closest providers. PAYERFUSION TECHNOLOGY
  32. 32. PayerFusion Services - Specialty ServicesOUR PROVIDER NETWORK • Avoids the use of multiple networks which are non-compliant and cause balance billing issues. • Also includes pharmacy network, transplant services, dental, vision and second opinion services. • Provider search available in 3 languages: English, Spanish & German • Network design that defines the best place of service based on cost and quality • Patient pointed to the most cost effective facility, without compromising freedom of choice • Compliant with US regulations such as “Patient Balance Billing Act” • Compliant with the “Network Leasing Act”
  34. 34. Web Portal - Fast Data Transfer • Allows for the monitoring of claim status changes • Facilitates the real-time transmission of claim information and associated documents (EOB, invoices, etc.) to client claim system • Supports the tracking of claim activity and changes from the moment the claim is entered to final pricing PAYERFUSION TECHNOLOGY
  35. 35. • Accessible via the Internet • Remotely hosted at a hardened data center • 99.9% guaranteed up-time • Utilizes 128-bit encryption (SSL-enabled) • Open interfaces to integrate with legacy systems • Multi-language support/multi time zone • Electronic Claims – 837 Format • Multi-currency real time conversion Web Portal • Electronic Payments • Handles sophisticated client business configurations • Role-based security • Developed using open-source technologies • Friendly user interface • Leverages strong workflow components and transaction processing engine PAYERFUSION TECHNOLOGY
  36. 36. • Automatic Call Distribution (ACD) • Real-time management through web interface • 360 degree view of call activity with user managed status • Up-to-the-minute insight into call center metrics to manage call center activity • Account level control on routing calls and running reports Call Center Technology PAYERFUSION TECHNOLOGY
  37. 37. • Phone calls are answered by live operator as per SLA. • Dedicated phone line to patients • Toll free number available within the USA (1-800- XXX-XXXX) • Auto-attendant available as back-up to human response failure. CALL CENTER PROTOCOL
  38. 38. Home screen with one-touch access to emergency contacts and closest urgent care clinic. Our Mobile Solution Provider search enabling global geo-targeted access to quality providers Patient health records including coverage information, existing conditions, medications and allergies. Easily contact insurance carrier, user designated providers and emergency contacts. PAYERFUSION TECHNOLOGY
  39. 39. • Financial - Superior cost containment results both in the short and long-term savings by controlling growth year over year in the average cost per claim. • Service – Our expertise and experience in healthcare reduces hassles and administrative burden both for our clients and their insured’s. • Compliance – We vigilantly monitor and adhere to continuously changing state and Federal regulations so you don't have to; that's how we are able to provide our clients with a zero balance billing guarantee. COMPETITIVE ADVANTAGES