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Pro act solutions marketing pieceDocument Transcript
TRU Services, LLC
ProAct® Solutions does not guarantee payment for claims under the Stop Loss Policy. All
applicable Plan Document Wording and Policy Language will apply.
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
• healthcare. With costs on
Specialty Pharmacy Programs
• the rise, who is making
Large Case Management
Specialty Neonatal Case Management
• sure you are realizing all
Plan Document Review
• 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
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
In-Network Billing Review
Medical Necessity Evaluation
Individual Hospital Bill Audit
**ProAct® Solutions does not guarantee payment for claims under the Stop-Loss Policy Page 3
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
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.
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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
ProAct Organ Transplant Program Includes:
Centers of Excellence Network
Review, Analysis and Process Result
Easy Referral System
ProAct® Organ Transplant Case Management Means:
Patient Oriented Service
Efficient Coordination and Communication Between Doctor, Patient, Family & Medical Plan
National/International Travel Arrangements
Efficient Evaluation and Authorization Process
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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.
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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.
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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
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
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
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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
We look forward to hearing from you.
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