An Introduction to
CovenantCare
An Alternate Funded
Healthcare Program

CovenantCare
An Alternate Funded Healthcare Program
About Covenant Administrators
Headquartered in Georgia, Covenant Administrators traces its beginnings to the
former Covenant Group, the parent company of three operating companies: Covenant
Management, Covenant Administrators, and MediCor. The Covenant Group’s history
extends back to another risk industry organization, J. Gordon Gaines. The Covenant
Group was formed in 1992 to address serious needs in the insurance market, such as
Workers’ Compensation and employee benefits. Subsequently, the Covenant Group
was sold to AmTrust and today operates separately under the AmTrust name.
In April 2004, Covenant Administrators, the health care TPA of the former Covenant
Group, consolidated its ownership from three managing partners to one. As founder
and principal, Jim Ballew has been responsible for the management and operations of
Covenant Administrators since its inception.
Today, operating under the Covenant Services Group umbrella, member companies
include Covenant Administrators with sales/service offices in Atlanta Georgia,
Clearwater, Florida, and Lafayette, Louisiana and MediCor, our fully URAC accredited
Utilization Review Company.
Our Focus
As a leading Third Party Administrator (TPA), Covenant Administrators concentration
is to be more than just a claims processor or even a claims manager, but to be a
Healthcare Risk Manager. Our global focus is to provide Health Risk Management
solutions that will have a dramatic impact on the bottom line costs by providing
techniques to eliminate exposure to risk and reduce the cost impact of know risks.
Our commitment to the level of service we provide is best exemplified by our name
itself. We are honor bound, far beyond the stipulations of any paper contracts
between us. We settle for no less than to exceed your expectations. At Covenant, we
believe and are committed to the following…
“Covenant...More Than A Promise”
Administrative Services
Covenant Administrators provides Health Benefits Risk Management Programs and
Administration Services to over 100,000 member lives by harnessing the industry’s
most powerful technology and applying sound fundamental healthcare strategies. Our
seasoned professionals help you design a benefits strategy to suit your company’s
needs, and implement the proper strategies to keep your costs to a minimum. During
every phase of your relationship with Covenant Administrators, you will experience the
highest level of customer service, delivered by professionals who have pledged to
process every claim, and treat every customer with integrity.
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CovenantCare
An Alternate Funded Healthcare Program
The CovenantCare Plan:
An Attractive Alternative for the Fully Insured Employer
The CovenantCare benefit program is an attractive self-funded alternative for employers and
health plan sponsors who are currently fully insured and want the advantages of self-funding
but are hesitant to leave the safety of fixed premiums and limited liability provided by fully
insured medical plans. In essence, it provides a way to apply health risk management
strategies to your benefit plan like large employer groups but with the same financial safe
harbors of fully insured programs. You will truly be able to take back control of your
healthcare benefit program. The benefits of choosing the CovenantCare Alternate Funding
Plan include the following:
Capping the Risk
Just like self-funded plan sponsor's use of aggregate reinsurance to cap maximum liability,
CovenantCare also caps the risk based on expected claims factors and fixed cost.
Profit Margins
With the CovenantCare plan, you keep for yourself the profit margins built into insurance
companies' premiums that are on top of your projected claims.
Access Your Claims
With CovenantCare, you can have access to your claims experience. This will allow you to
control your healthcare program.
Healthcare Risk Management
CoveantCare, you will have at your finger tips true risk management programs that
allows you to control the future outcomes of your plan. You will be able to reduce or
eliminate the future impact of claims.
Lower Maximum Cost
The maximum cost of CoveantCare is much lower than traditional specific and
aggregate products and favorably resembles a fully insured program. CovenantCare
includes a full funding feature for aggregate factors on a monthly basis. Because the
aggregate corridor is much lower, the maximum cost is lower. Similar to fully insured plan,
CovenantCare affords the client consistent monthly budgeting for plan costs.
No Lasers - Even at Renewal
A great advantage to CovenantCare is that no lasers will be placed as a condition of
renewal.
3

CovenantCare
An Alternate Funded Healthcare Program
Client Funding is Capped - No More Cash Calls
Traditional specific and aggregate products require the client to fund amounts above the
specific deductible and aggregate attachment point, then wait for reimbursement. With
CovenantCare, the only monies the client is required to fund on a monthly basis are
aggregate premium rates and aggregate factors. CovenantCare Plan will automatically
and immediately fund any claims above the monthly funded equivalents.
Potential for Reimbursement
Unlike fully insured product, should the actual claims come in lower than the attachment
point at year-end, reimbursement is a possibility. This is not an option with a fully insured
product.
Advantages of CovenantCare compared to Fully Insured and Traditional Self-Funding
CovenantCare
Fully Insured CovenantCare Self-Funded
Capped Funding Yes Yes No
Lasers No No Yes
Access to Claims
Experience >100 Yes Yes
Plan Costs Fixed Fixed Variable
Administration Higher Cost, Lower Cost, Lower Cost,
Less Service Great Service Great Service
Cash Calls None None Weekly funding of
claims up to specific
per member
Potential for Year-End No Yes Yes
Reimbursement
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
OUR RISK MANAGEMENT SOLUTION
Covenant’s CAST Risk Management Program will provide your company with a
comprehensive and seamless plan that will eliminate exposures to risk by decreasing
the frequency of high risk or potentially high risk opportunities. It will also provide
results in reducing unit costs. Our risk management strategy will pave the way to
allowing your organization to win the battle over rising healthcare costs.
♦ Bravo Wellness - specializes in developing flexible, HIPAA-compliant corporate
wellness programs that give employees financial rewards for achieving healthy
outcomes. Employers will realize an immediate reduction to their healthcare costs
by 6%-9% through this lifestyle management program that focuses on incentive-
based wellness initiatives. It can also be expected that at least 5% reduction in
claims utilization can be realized. New legislation allows employer-sponsored
health plans to provide results-based incentives for wellness.
Bravo Wellness works in conjunction with the healthcare plan to create a
solution that ties employee participation and their wellness screening results
(i.e., tobacco use, cholesterol, body mass index and blood pressure) to what
they pay for healthcare coverage or what their benefits are.
HOW IMMEDIATE SAVINGS ARE GENERATED
Employee # 1 Profile: Passed 0 Goals
Obese, Smoker, High Blood Pressure, High Cholesterol,
No Medical Issues Preventing Healthier Lifestyle.
Traditional Bravo Wellness
Cost-Shared Model Model
Total Monthly Premium $500 $500
Employer Share $400 $300
Employee Share $100 $200
Annual Employer Cost: $4800 $3600
Year 1 Savings Per Person: $1200
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
What kinds of incentives encourage employees to get serious about their
health? You can reward wellness in a number of ways. Sample incentives
include:
⇒ A premium contribution deduction or increase tied to the results of a health
evaluation.
⇒ A variable plan design or cost-sharing mechanism, such as deductibles or
co-pays based upon the results of a health evaluation.
⇒ A variable health reimbursement account (HRA) deposit tied to the results
of a health evaluation.
Employee # 2 Profile: Passed 2 Goals
Obese, High Blood Pressure, Normal Cholesterol, Non-Smoker
No Medical Issues Preventing Healthier Lifestyle.
Traditional Bravo Wellness
Cost-Shared Model Model
Total Monthly Premium $500 $500
Employer Share $400 $350
Employee Share $100 $150
Annual Employer Cost: $4800 $4200
Year 1 Savings Per Person: $600
Employee # 3 Profile: Passed 4 Goals
Normal Weight, Non-Smoker, High Cholesterol (Under
Physician Care Due to Medical Issue) Normal Blood Pressure
Traditional Bravo Wellness
Cost-Shared Model Model
Total Monthly Premium $500 $500
Employer Share $400 $400
Employee Share $100 $100
Annual Employer Cost: $4800 $4800
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
♦ TelaDoc Medical Services - is a national network of licensed, board
certified primary care physicians offering cross coverage medical
consultations via the telephone 24 hours a day, 7 days a week.
TelaDoc consulting physicians treat illnesses that arise quickly and tend
to run a brief course, typically 5-10 days. Consulting physicians address
acute, episodic, self-limited and minor illnesses as opposed to chronic
conditions such as hypertension, epilepsy, or diabetes. TelaDoc
addresses three of the key challenges facing healthcare today…..
Access, Affordability, and Convenience.
TelaDoc can be used to treat problems such as
Allergies Bronchitis Gastroenteritis Pharyngitis
Respiratory Rx Refill Sinusitis Urinary Tract
Infection (short term Infections
only)
TelaDoc Benefits:
⇒ Significant cost savings.
⇒ No need to take time off to see a doctor.
⇒ Access to care for rural residents and those who travel.
⇒ Consult with physicians who diagnose medical
problems and prescribe medication when appropriate.
⇒ Access to physician within three hours or the
consultation is free.
⇒ Physician consults at a fraction of the cost of a
physician office, urgent care, or ER visit.
⇒ Access to a personal, portable, and free electronic
health record (EHR) using HIPAA compliant secure
servers.
⇒ TelaDoc is an FSA & HSA eligible expense.
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
♦ MAP - Medical Advocate Program - assists employees by showing how
they can get more value out of their healthcare benefits, while at the same
time helping them to become more educated purchasers of healthcare.
With just a single phone call, MAP offers one-on-one personal assistance
with qualified healthcare professionals with your medical questions, help
with finding the highest quality doctors and facilities in the area, and
understanding treatment options. All information discussed with MAP
representatives is strictly confidential.
Through Information, Education, Counseling, and Direction, MAP is
bridging your healthcare plan to work better for you when….
⇒ You want help identifying the best doctors.
⇒ You would like information on physicians and
medical facilities.
⇒ You would like a second opinion/treatment
options.
⇒ You want to discuss your health concerns.
⇒ You are having trouble navigating the medical
maze.
Results:
⇒ Save valuable time and money in making
crucial decisions.
⇒ Have a personal guide in obtaining the best and
most cost-effective healthcare.
⇒ The end result better outcomes.
⇒ Will be another catalyst in reversing the
healthcare trend.
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
♦ MEDai Predictive / Risk Analysis - is a prediction engine that applies the
right combination of linear and non-linear models to correctly identify
patients at risk and forecast future health plan costs. This technology
allows an employer to be proactive in establishing proper programs that will
manage and alleviate health conditions before they become a strain on
healthcare costs. It will also identify gaps in care and immediately
recognize those individuals with the greatest impact potential from both a
financial and quality of life perspective.
Users of the MEDai tool are more effectively able to:
1) Accurately select the members or
groups with the highest potential for
savings.
2) Objectively decide which members
would benefit from high-cost/high-
touch or low-cost/low-touch.
3) Quickly identify which members are
not following evidenced-based
guideline protocols for their
4) Engage physicians in the total care their condition.
members.
5) Provide employers with comprehensive
summary reporting that includes prior
experience, future risk profiles and
disease prevalence for their entire
population.
6) Provide Employer Groups with return on
investment information related to care
management activities.
7) Provide Employer Groups with
utilization and cost comparisons
against benchmarks by disease.
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
♦ MEDInnovations - is a suite of loss control and decision support
capabilities that will improve the management of medical risk.
MEDInnovations works in the following arenas to improve cost outcomes for
an employer group.
1) Integrated Fraud & Abuse / Detection &
Prevention Suite Integrated Fraud & Abuse
Detection Strategy
Based on peer-to-peer Advanced learning
comparisons of historical models that score
data, individual providers individual claims
are selected for prepayment before payment and
Investigation Analytic reflect mathematical
a) Provider Match Program
probability of fraud
Modeling
Provider Centric
b) Fraud Diagnostics
Applied to all claims
as submitted,
proprietary rules Mines catastrophic
and catch all codes,
and pattern Claim Centric Data Mining re-admissions,
recognition
analytics used to outliers, etc.
c) Intelligent Fraud Analytics
spot individual
claims linked to
suspect behavior
Fraud & Abuse
d) TruClaimsm Code Edit Compliance 7
e) Case File Investigations Unit
2) Repricing Optimizers
a) AccessPlus PPO Features &
TruClaim Rule Defense Look Up
sm
Benefits TC3 Anti-Fraud Solutions
⇒ Achieve a PPO discount on • Detection
– Provider Match Program
Scripted for
Customer
Service staff
72% of retail claims –
–
Analytics-Intelligent Claim Surveillance
Fraud Diagnostics
– Client Referrals
nationally. • Investigation
– Pre-payment
Fully
Referenced ⇒ Average discount nationally – Post-payment
• Education
on all bill types of 26%. – Anti-fraud Awareness Training
Fraud & Abuse Fraud & Abuse
Repricing Optimizer
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Data Analytics
⇒ No minimum dollar
threshold.
b) Provider R&C Negotiations
Features & Benefits
⇒ Medicare benchmarks
establish baseline for
reasonable reimbursement.
⇒ Can be utilized for both in-
Factors in Rising Health Care Costs
The Mindset Behind
Fraud & Abuse
network and out-of-network Percent saying each is “one of the single biggest factors in rising health care costs”:
• Certain providers believe that
it is acceptable to “bend the
truth” when submitting claims
Suspected Fraud Cases by
Perpetrator Type
claims.
⇒ Negotiate from net cost up
due to earnings squeeze.
Consumer
• In a study published in the 10% Other 10%
Journal of American Medical Association :
– 54% of physicians reported
using deception of third party
payers to obtain benefits.
Facility 8%
rather than billed charge
– 39% of physicians reported
Fraud & Abuse
exaggeration of patient’s
condition, changing a
diagnosis or reporting signs or
symptoms that did not exist.
Medical
Prof. 72%
down. Fraud & Abuse
Source: ABC News/Kaiser Family Foundation/USA Today Health Care in America Survey (conducted September 7-12, 2006.
⇒ National average savings
Repricing Optimizer
4
Data Analytics
6
range of 18%-34% on all bill
types.
⇒ Provider sign-off with no
balance billing to member.
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
♦ Lab Card - is a voluntary benefit enhancement that will allow covered
employees and their eligible dependents the option to receive all covered
outpatient laboratory testing at NO cost to them. Payers, by working
directly with Quest Diagnostics, are able to take advantage of cost-effective
laboratory services and avoid additional third-party mark-up. The Lab Card
Program saves employers approximately 30%-60% on outpatient laboratory
testing, and allows employees to receive testing with no out-of-pocket cost
when they use the benefit.
Employer Benefit:
⇒ Approximately 30%-60% savings on
outpatient laboratory testing.
⇒ Has the potential of reducing total cost for
medical benefits up to 2%.
⇒ Able to provide new value-added benefit for
employees.
⇒ Easy to implement.
⇒ NO startup or ongoing administrative costs.
⇒ Member education and communication
materials provided at no cost.
⇒ Standard activity and savings reports
provided at no cost.
Employee Benefit:
⇒ No out-of-pocket costs for outpatient
laboratory testing when their Lab Card
is used.
⇒ Voluntary, Optional benefit.
⇒ No need to change current physician.
⇒ Quality laboratory testing.
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CovenantCare
An Alternate Funded Healthcare Program
Covenant Administrators is…...
Your Health Benefits Risk Management Solution
The Covenant CAST Risk Management Funnel of Savings
Lifestyle Management
6% Savings 15% Savings
MEDInnovations
MEDai
4% Savings 10% Savings
TelaDoc
Lab Card
3% Savings 10% Savings
Covenant
Rx Initiative
5% Savings 8% Savings
MAP
18% - 43% Potential Claims Reduction
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