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Pro act solutions marketing piece Document Transcript

  • 1. TRU Services, LLC [PROACT® SOLUTIONS] ProAct® Solutions does not guarantee payment for claims under the Stop Loss Policy. All applicable Plan Document Wording and Policy Language will apply.
  • 2. H ProAct® Solutions ere at TRU Services, LLC, we review and evaluate on an ongoing basis the different services that our clients are using in the different “care management” arenas. Are the network services providing adequate discounts? Are care managers providing rational care strategies and offering alternatives if appropriate? How are specialty services such as dialysis specialty injectable drugs affecting the losses of the group? Are there discounts in place for these services? These questions and many more are answered utilizing TRU Services ProAct® Solutions department at no additional charge. Our services are provided as an added level of service to show you that we care about our business relationship and the integrity of your health benefits plan just as much as you do. As our underwriting departments review loss ratio’s to provide you with the most competitive renewal rate, one of the things that we look at is the type of services being provided to the groups to mitigate their losses from ground up. Our ProAct® Solutions Department is monitored by our consulting Medical Director as well as two in-house Registered Nurses. We can readily assist you in “Never has there been a securing an array of cost and quality controls with access to networks for claim related medical expertise. more crucial time to keep a We have access to a number of networks including: watchful eye on the cost of Claim Cost Containment Dialysis Services • healthcare. With costs on Transplant Coordination • Specialty Pharmacy Programs • the rise, who is making Large Case Management • Specialty Neonatal Case Management • sure you are realizing all Plan Document Review • Subrogation • the savings possible?” PPO and Provider Evaluation • Fee Negotiation and Recovery • • As our industry evolves we as companies also must evolve, care management and wellness of our employees is at the forefront of the fight against the spiraling cost of healthcare. Working together we can achieve real, hard dollar results that will maintain the financial integrity of your clients’ employee benefit plan. Please read on to find out more about the services we offer. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 2
  • 3. Claim Cost Containment The ProAct® Solutions Department is available to assist our clients with claim cost containment through a variety of programs. We facilitate claim cost savings by providing access to reputable and reliable vendors selected especially to meet the needs of our industry. Whether through reviewing the effectiveness of existing networks, individual bill audit, direct bill negotiations or providing access to a variety of networks to assist with addressing gaps in existing networks; we work with you to achieve unsurpassed savings for your client. Working directly with TRU will allow you access to our vendor partners who specialize in cost containment. When you receive early notification of an individual’s intent to obtain out-of-network services or you receive a billing for out-of-network services, involve ProAct® and we will provide access to our specialized vendors even if it will not exceed the plans specific deductible. Areas we can help provide substantial savings are: UCR Review for Implantable Devices Out-of-Network Claim Repricing o In-Network Billing Review o Medical Necessity Evaluation o Individual Hospital Bill Audit o o **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 3
  • 4. Dialysis Services End Stage Renal Disease (ESRD) is one of the fasted growing disease groups in the United States. Dialysis costs have skyrocketed and are making a significant impact on self insured client’s health care costs. TRU Services is working with cutting edge and effective cost containment vendors that have a proven track record of obtaining savings. ESRD U & C Repricing Program When appropriate plan language is in place and defendable ERISA appropriate U & C repricing is applied, savings average 84%. If the plans members have Medicare Part B there is no member balance billing. A good vendor should be able to review plan language for you. Note: Please refer to Medicare Eligibility Guidelines which can be found at (www. Epogen Carve out Program If the member is willing to self inject Epogen at home, TRU has access to vendors who will require physicians to provide the prescription be filled by an outside vendor. Many times the markup on Epogen exceeds the charges for dialysis services. Home training is included in the program at no additional fee. When combined with a network or other discount the total bill discount typically exceeds 60%. Negotiated and PPO Discounts Vendors can negotiate discounts or access PPO discounts at most dialysis centers as well as assist in placement at lower cost centers. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 4
  • 5. Organ Transplant Program Helping your clients provide high quality health care while controlling high costs associated with solid organ, bone marrow and stem cell transplants can sometimes require utilization of ProAct® Solutions organ transplant program. The ProAct® organ transplant program provides patients with world class care from one of its nationwide transplant facilities. All facilities are board-certified “Centers of Excellence,” a classification only earned by adhering to the highest medical standards and by passing the most stringent medical accreditation process. Critical care nurses, not administrators, act as transplant coordinators and patient advocates. They will help patients coordinate and communicate with doctors, family members and plan administrators. ProAct Organ Transplant Program Includes: Centers of Excellence Network Patient Advocacy • Outcome Management • Review, Analysis and Process Result • Easy Referral System • • ProAct® Organ Transplant Case Management Means: Quality Care Patient Oriented Service • Efficient Coordination and Communication Between Doctor, Patient, Family & Medical Plan • administrators • National/International Travel Arrangements Efficient Evaluation and Authorization Process • Cost Containment • • **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 5
  • 6. Large Case Management Program No one can ever be prepared for a catastrophic medical condition, certainly not the patient. Who can be prepared for the pain, hardships and emotional trauma? At times like these the patient needs to know it is not necessary to face it alone. Most times, employers are caught by surprise and concern for their employee is overshadowed by economic concerns. Cost containment issues arise and questions are asked for which there are no good answers. Helping employees prepare for these trying times requires proactive thinking. The TRU Services, LLC ProAct® Large Case Management Program uses a cooperative team approach. We help employers identify large cases before they become too big to manage. By identifying potential catastrophic claims early, TRU Services can help make sure patients receive optimum medical care. Referral to an appropriate large case management vendor will promote the best outcome possible. Specialty Neonatal Case Management With access to a number of vendors who specialize in Neonatal case management, ProAct® Solutions department can provide a resolution to your Neonatal needs. Neonatal case management advocates wellness, prevention of uncontrolled disease states, and in the event of a need for healthcare intervention, the provision of only the highest quality care-improving ease of access and appropriate utilization of a highly skilled continuum of healthcare provider partners. Retention and loyalty based focus on maternity management designed to promote maternal and fetal health while helping the organization reduce costs by providing meaningful employee support. Neonatal case management helps expectants mothers get appropriate prenatal care, follows her doctor or midwife’s direction and seeks care when it is most effective. As a result specialty neonatal case management can help keep your group’s claim experience down. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 6
  • 7. Plan Document Wording Innovative Plan Document Design: Many plan documents are antiquated and do not support sound claims processing. In certain circumstances revisions may be enough to repair the issue, but frequently documents require an overhaul. Our vendors develop plan documents customized to meet unique plan specifications. All plan documents developed by our vendors will be strong enough to withstand the latest legal challenges. Also, our vendors standard language can be modified to fit individual plan needs to ensure the terms accurately reflect the true intentions of the plan. Plan Document Review and Revision: A plan’s rights are only as good as the plan language involved. Incomplete wording or a lack of essential provisions will reduce or eliminate savings opportunities. To eliminate this risk, our vendors will review and analyze plan documents, make key recommendations, stay abreast of legal developments, and provide provisions intended to maximize plan rights. To accommodate unique requirements, our vendors will customize plan provisions based on clients’ needs. Regulatory and Legal Compliance Updates: Changes in the law force plans to comply with new regulations faster than they can change their administrative procedures. Our vendors maintain and offer regular legal updates relating to regulatory and legal changes in the industry. Upon subscription with our vendors, subscribers may access legal compliance issues and updated plan document provisions for all industry topics. Third Party Agreement Review: Plans must obey the terms of the plan document and may not agree to step beyond the boundaries set by those provisions. Yet many third party entities expect plan administrators to exceed their fiduciary duties on a regular basis. Our vendors will review clients’ third party agreements to ensure the terms do not contradict plan terms. In addition to said analysis, we will draft contractual language and customize policy language as well. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 7
  • 8. Specialty Pharmacy Programs Specialty medications are high cost, oral, injectable, infused or inhaled medications that are either self-administered or administered by a healthcare provider and used or obtained in an outpatient or home setting. TRU works directly with specialty pharmacy provider to achieve greater control of specialty drugs by helping reduce laser and overall aggregate factors. Innovative programs that effectively manage costs by addressing specialty drugs found under both the major medical and PBM benefit are recommended by the ProAct® Solutions department. Prescription drugs continue to lead all other health care services in spending growth. With this growth comes emerging areas of injectable and infusible drugs highlighting the need for Specialty Pharmacy Services vendors that offer drug benefit management programs. As new and more effective injectable and infusible treatments are developed the same controls that exist for oral medications do not exist for these drugs. This category of drugs typically falls outside the scope of PBM services since it is managed under the major medical benefit and represents approximately $40 billion of the estimated $220 billion annual drug spend. Plan Document wording should include an effective date, the Plan Name, description of Specialty Drugs and what they may include. The Plan requirements may specify a particular vendor or restring reimbursement and give details as to how it is covered. It should also confirm that experimental and investigational treatments will still be excluded. Sample wording should be obtained by the vendor. Program Features to Look for in a Vendor Incorporates tools to manage major medical – PBM benefit overlap, separate bundled drug and service Benefit Management: charges and ensure that claims are directed to the correct payment source. Offer NDC based repricing of medical pharmacy claims with AWP minus pricing structure to ensure that Conversion of Medical J Codes to NDC Based Processing: drug claim reimbursements are based on the most competitive drug prices. Provides a dedicated account team offering a single point of contact for clients and experienced plan Experience Account Management: implementation at the TPA and client level. Provides clinical pharmacy experts and case managers who review key clinical data and new Clinical Services and Drug Protocol Management: medications and protocols to ensure FDAA guideline compliance. Data Management tools allow for rebate data collection, patient compliance monitoring, drug utilization Data Management Tools: reviews and client level reporting. Save 15-40% on injectable and infusible drug costs. Achieve greater control over specialty drug deliver Benefits: and associated costs. Aggressive discounts that impact lasers and overall aggregate factors. Uncoupled bundled drug and medical service charges. Accurate claims repricing of medical pharmacy claims. Manage data effectively with therapeutic and utilization report. Potential additional earnings to the TPA or group. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 8
  • 9. Care Management in Today’s Self Funded World Never has Care Management been more crucial to the integrity of self insured employer plans. As the cost of healthcare continues to rise and healthcare reform is phased in, Care Management of self funded health plans is a critical focus for plans, administrators and reinsurers. TRU Services ProAct® Solutions department is a resource available to you and your clients to help find and create savings across all arenas of care management. ProAct® Solutions scrubs your clients’ first dollar claim data daily to ensure that appropriate savings are being realized throughout the life of the plan. ProAct® comes at no extra charge to you and your clients and using a no pressure approach the option is yours. Savings through ProAct® lead to measurable results realized at the employer plan level as well as during renewal. When claim dollars are saved, everyone wins. Benefits from using ProAct® as a resource: Integrity of the Plan 1st Dollar Savings for Plan Practical Renewal Rates Comfort of Knowing We Are • • Working for You • • Please contact our ProAct® Department Call us at (978) 564 – 0200 Or E-mail proactreferrals@truservices.com. We look forward to hearing from you. **ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 9