ICS - Integrated Services  Total Service Solution  Overview Prepared for :
Overview of Integrated Services <ul><li>Lines of Business:  WC / Auto / FELA / Liability/ Group Health </li></ul><ul><li>2...
ICS - Integrated Services Overview <ul><li>Genesis of ICS </li></ul><ul><li>Strategic Partnership with MCMC </li></ul><ul>...
Call Center Services
Call Center Services - Component Benefit <ul><li>Promotes Early Intervention with prompt notification of injury, illness, ...
Call Center Utilization
For Client A, new injuries that are reported 8 Days of Greater incurred roughly 140% more in medical costs than those case...
Early Intervention Nurse Case Management/EPO Network Services
Early Intervention/Telephonic Case Management <ul><li>Component Overview & Benefits </li></ul><ul><ul><li>Prompt and concu...
Early Intervention/Telephonic Case Management <ul><li>Upon completion of an Initial Assessment, Nurse Case Manager will ev...
Monthly Saved Days Analysis - Comparison to National Benchmark For this national client, the average monthly “saved” lost ...
Transitional Duty Outcomes - New Employees Entering Program For this national client, since FY02, there have been over 1,7...
Average Lost Time Days by Lost Time Claim CY 1999 was full year prior to implementation of current TCM Program
Exclusive Occupational Health Network Overview <ul><li>Specially designed network of occupational health providers that ar...
Exclusive Occupational Health Network Overview <ul><li>Establishment of “Service Level Agreements” to provide an injured e...
Pre Certification/Utilization Review Services
Utilization Review  - Component Benefits <ul><li>Detailed determination reporting with complete clinical rationale and tre...
Medical Bill Review & PPO Fusion Services
Medical Bill Review Services <ul><li>Application of all state fee schedule/UCR values, jurisdictional rules, and CCI/OCE e...
Medical Bill Review Components <ul><ul><li>Claim Handling/Intake </li></ul></ul><ul><ul><ul><li>Mailroom </li></ul></ul></...
Medical Bill Review – Service Overview <ul><li>Automated Client specific utilization management parameters </li></ul><ul><...
<ul><li>PPO application performed on proprietary software platforms </li></ul><ul><ul><li>Setup customized per State for m...
PPO/Specialty Savings & Penetration Breakdown <ul><li>Tier 1 % of Total Savings: 29% </li></ul><ul><li>Tier 2 % of Total S...
<ul><li>Transparent claimant, provider, and employer tool, customizable by client  </li></ul><ul><li>Consolidates all pros...
IC_Solutions – Specialty Bill Review Services
<ul><ul><li>IC_Solutions offers a suite of services to address the specialty bill review needs of Workers’ Compensation, A...
<ul><li>Code Review -  Over $7,750,000 in Savings for CY 2009 </li></ul><ul><ul><li>RN review of coding and supporting doc...
<ul><ul><li>HIPPO contains information on millions of medical transactions, including costs, charges, PPO hits, and prevai...
<ul><ul><li>Referrals to IC_Solutions for anyone of our services is the model of flexibility, including: </li></ul></ul><u...
Independent Medical Evaluation & Physician Review Services
Medical Evaluation Services <ul><li>Multi-disciplinary network of Board-Certified physicians </li></ul><ul><li>Providers t...
Independent Peer Review <ul><ul><li>25+ years </li></ul></ul><ul><ul><li>45,000+ reviews performed in 2009 </li></ul></ul>...
<ul><ul><ul><li>National Reviewer Panel </li></ul></ul></ul><ul><ul><ul><li>Over 1,100 reviewers </li></ul></ul></ul><ul><...
Medicare Set Aside
Medicare Set Aside Services <ul><li>Experienced nurses certified in life care planning available to review medical records...
Fraud Abatement & Record Retrieval Services
Fraud Abatement Services <ul><li>National service capability </li></ul><ul><li>Services: </li></ul><ul><ul><li>Mobile and ...
Record Retrieval Services <ul><li>National service capability </li></ul><ul><li>Service offering: </li></ul><ul><ul><li>Au...
Proprietary Technology – WebOPUS Case Management Portal
Overview of WebOPUS -  <ul><li>Robust case management system designed for the proactive case manager that creates bottom l...
WebOPUS Capabilities - Roles Supported <ul><li>Case Manager & Coordinator </li></ul><ul><li>Utilization Review Nurse & Coo...
WebOPUS Capabilities - Modules Supported <ul><li>First Report of Injury/Illness/Absence/Accident/Disability Module </li></...
WebOPUS Capabilities - Core Section Overview <ul><li>Activities Section </li></ul><ul><ul><li>Search and Attach Treating M...
WebOPUS - Browser Tool <ul><li>Facilitates communication with real-time access to user friendly, web-based care management...
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  • Tillingast Towers Perrin Other Notable events CIRMA Acquisition of RHH Satellite Claims office in Meriden Move of Claims to New Haven Linda Brooke to Ken Martino to Mike Rhyner to Bruce Bette Slother to Dave D to Bruce Clinger Claims dept reorgs // new SW implemented Softening of insurance market CareSys Sold from Value to Anthem. From Anthem to Continuum Many operational work flows changes
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  • ICS_services overview_template

    1. 1. ICS - Integrated Services Total Service Solution Overview Prepared for :
    2. 2. Overview of Integrated Services <ul><li>Lines of Business: WC / Auto / FELA / Liability/ Group Health </li></ul><ul><li>24/7 Claim Reporting/First Report of Injury/Absence Mgmt Call Center </li></ul><ul><li>Early Intervention Telephonic Case Management / Utilization Management </li></ul><ul><li>EPO Network Management </li></ul><ul><li>Pre-Authorization / Utilization Review </li></ul><ul><li>Medical Bill Review – Online & Paperless </li></ul><ul><li>PPO Fusion </li></ul><ul><li>Specialty Nurse Audit & Out of Network Signed Agreements </li></ul><ul><li>Independent Medical Evaluations </li></ul><ul><li>Independent Physician Reviews </li></ul><ul><li>Pharmacy Benefit Management & Durable Medical Equipment Programs </li></ul><ul><li>Medicare Set Aside </li></ul><ul><li>Medical Record Litigation Support </li></ul><ul><li>Fraud & Investigative Services </li></ul><ul><li>Proprietary web-based technology solutions </li></ul>
    3. 3. ICS - Integrated Services Overview <ul><li>Genesis of ICS </li></ul><ul><li>Strategic Partnership with MCMC </li></ul><ul><li>Disability and medical care management services </li></ul><ul><li>Leader in technology-driven, early intervention case management services </li></ul><ul><li>Extensive experience within both public and private sector, risk pools, carriers, third party administrators, self insured/administered, and transportation industry </li></ul><ul><li>Comprehensive and innovative technology solutions, including extensive interface capabilities </li></ul><ul><li>Documented savings and results </li></ul><ul><li>Flexibility to customize all aspects of service to ensure programs meet unique needs of each client </li></ul>
    4. 4. Call Center Services
    5. 5. Call Center Services - Component Benefit <ul><li>Promotes Early Intervention with prompt notification of injury, illness, accident and/or absence </li></ul><ul><li>Dedicated Toll-free number available 24 hours a day/7 days a week </li></ul><ul><li>Designed to complete all mandatory and client specific reporting forms </li></ul><ul><li>Allows for immediate verification and access of information via Auto Email Alert process and WebOPUS Browser technology </li></ul><ul><li>Designed to eliminate paper & labor intensive processes </li></ul><ul><li>Improves timeliness of reporting of injury,illness, accident and/or absence, allowing for Care Management to begin immediately </li></ul><ul><li>Provides for Mandatory and/or “Soft” channeling to appropriate PPO/EPO Network provider </li></ul><ul><li>Provides for “Call ahead” process to the appropriate facility </li></ul><ul><li>Provides for Flagging between various payment systems </li></ul>
    6. 6. Call Center Utilization
    7. 7. For Client A, new injuries that are reported 8 Days of Greater incurred roughly 140% more in medical costs than those cases that are reported the Same Day. Average Medical Cost by Lag Time Category
    8. 8. Early Intervention Nurse Case Management/EPO Network Services
    9. 9. Early Intervention/Telephonic Case Management <ul><li>Component Overview & Benefits </li></ul><ul><ul><li>Prompt and concurrent review and management of the medical care of injured employees ensuring the utilization of the best and most appropriate medical care </li></ul></ul><ul><ul><li>Timely and continuous contacts with injured employee, work site coordinator, medical provider, and claims adjustor until claim resolution promoting effective communication </li></ul></ul><ul><ul><li>Focused return to work coordination by managing the disability duration of injured employees compared to national best practice guidelines </li></ul></ul><ul><ul><li>Communication of Care Management Episodes to all interested parties via EDI with Claims System, Auto Email Alerts, WebOPUS ® Internet Browser, and Auto Fax Server </li></ul></ul><ul><ul><li>Promote employee advocacy and goodwill </li></ul></ul>
    10. 10. Early Intervention/Telephonic Case Management <ul><li>Upon completion of an Initial Assessment, Nurse Case Manager will evaluate: </li></ul><ul><ul><li>Medical Management • Treatment Plan • Disability Duration </li></ul></ul><ul><ul><li>Return to Work Plan • Pre-Authorization/Utilization Review </li></ul></ul><ul><ul><li>Necessity for Peer Review, Medical Evaluation or Field Case Management </li></ul></ul><ul><li>Continuously update work site coordinator, claims adjustor or any other interested party with care management milestones via: </li></ul><ul><ul><li>EDI to Claims System </li></ul></ul><ul><ul><li>Email Alerts to all interested parties </li></ul></ul><ul><ul><li>WebOPUS ® Browser accessibility </li></ul></ul>
    11. 11. Monthly Saved Days Analysis - Comparison to National Benchmark For this national client, the average monthly “saved” lost time days has increased by nearly 200% over the past 2 full calendar years. The “saved” days is measured on closed Lost Time cases and the number of lost time days incurred measured against the expected disability duration using national best practice benchmarks
    12. 12. Transitional Duty Outcomes - New Employees Entering Program For this national client, since FY02, there have been over 1,700 new employees who have benefited from the Transitional Duty Program.
    13. 13. Average Lost Time Days by Lost Time Claim CY 1999 was full year prior to implementation of current TCM Program
    14. 14. Exclusive Occupational Health Network Overview <ul><li>Specially designed network of occupational health providers that are trained to understand and treat a work-related injury </li></ul><ul><li>Occupational Health facilities that are in close proximity to employer locations </li></ul><ul><li>Utilization of Occupational Health facilities that have gone through and met extensive credentialing criteria </li></ul><ul><li>Utilization of Occupational Health facilities that have gone through and successfully met rigorous Site Visits </li></ul><ul><li>Ongoing Site Visits are completed to ensure compliance . </li></ul>
    15. 15. Exclusive Occupational Health Network Overview <ul><li>Establishment of “Service Level Agreements” to provide an injured employee with the following “Expectations”: </li></ul><ul><ul><li>Expect to receive medical care within 30 minutes of arrival. (Remember: Emergencies should always go to the nearest ER) </li></ul></ul><ul><ul><li>Expect that the facility be near the worksite, be clean and have the equipment necessary to treat their injury appropriately </li></ul></ul><ul><ul><li>Expect that the treating medical provider should be able to answer your questions and provide you with information about your injury. </li></ul></ul><ul><ul><li>Expect that the medical provider is communicating with your Nurse Case Manager to ensure you are receiving the best and most appropriate medical care </li></ul></ul><ul><ul><li>Expect that the Occupational Health facility that treated your work related injury is also certified by Health Services to complete a Return To Work Physical. (If necessary, this ensures your Physical will be completed by a facility that knows you and your injury.) </li></ul></ul><ul><ul><li>Expect to find a contracted Occupational Health facility via Intranet site or by calling the Call Center. </li></ul></ul>
    16. 16. Pre Certification/Utilization Review Services
    17. 17. Utilization Review - Component Benefits <ul><li>Detailed determination reporting with complete clinical rationale and treatment guidelines used for decision making </li></ul><ul><li>Seamless integration with Telephonic Case Management and Medical Bill Review </li></ul><ul><li>Pre-certification Model </li></ul><ul><ul><li>Medical Necessity Review </li></ul></ul><ul><ul><li>Full utilization management including concurrent review </li></ul></ul><ul><li>Physician Review Model </li></ul><ul><ul><li>Criteria based referral </li></ul></ul><ul><ul><li>Peer to peer board certified specialties </li></ul></ul><ul><ul><li>Independent Medical Evaluations </li></ul></ul><ul><li>Case Management Model </li></ul><ul><ul><li>Early Intervention </li></ul></ul><ul><ul><li>Field Case Management as necessary </li></ul></ul><ul><ul><li>Cost Projection </li></ul></ul>
    18. 18. Medical Bill Review & PPO Fusion Services
    19. 19. Medical Bill Review Services <ul><li>Application of all state fee schedule/UCR values, jurisdictional rules, and CCI/OCE edits </li></ul><ul><li>Access to multiple network/out of network fee discounts </li></ul><ul><li>Specialty review services for additional savings </li></ul><ul><li>Guaranteed turnaround times </li></ul><ul><li>Real Time interface to share data with UR and case management services </li></ul><ul><li>Dedicated toll-free provider assistance hotline </li></ul><ul><li>Automated check writing </li></ul>
    20. 20. Medical Bill Review Components <ul><ul><li>Claim Handling/Intake </li></ul></ul><ul><ul><ul><li>Mailroom </li></ul></ul></ul><ul><ul><ul><li>Claim Indexing </li></ul></ul></ul><ul><ul><ul><li>Document Management </li></ul></ul></ul><ul><ul><li>Adjudication </li></ul></ul><ul><ul><ul><li>Fee Schedule & UCR Application </li></ul></ul></ul><ul><ul><ul><li>Nurse Code Review </li></ul></ul></ul><ul><ul><ul><li>Nurse Desk Audit </li></ul></ul></ul><ul><ul><ul><li>PPO Fusion Application </li></ul></ul></ul><ul><ul><ul><li>Out of Network Bill Signed Negotiations </li></ul></ul></ul><ul><ul><ul><li>Online Medical Bill Review & Approval </li></ul></ul></ul><ul><ul><ul><li>Operational Throughput </li></ul></ul></ul>
    21. 21. Medical Bill Review – Service Overview <ul><li>Automated Client specific utilization management parameters </li></ul><ul><li>Customizable claim edits for exception processing </li></ul><ul><li>Access to multiple network fee discounts </li></ul><ul><li>Application of State Fee Schedule/UCR values, State rules and CCI Edits </li></ul><ul><li>Guaranteed turnaround time to enhance provider relations </li></ul><ul><li>Comprehensive status & outcome reports including provider profiling </li></ul><ul><li>Linked to WebOPUS case management software </li></ul><ul><li>Electronic interface in sharing Closed/Denied information to prevent improper payments </li></ul><ul><li>Electronic link with Group Health carriers to prevent “double dipping” </li></ul><ul><li>Automated check writing capabilities </li></ul><ul><li>Dedicated toll free Provider Assistance Hotline </li></ul><ul><li>Mail Room outsource/claim indexing services </li></ul><ul><li>Ability to offer an online Approval/Denial portal for Adjusters to make a decision on a scanned medical bill. Creating the “paperless” medical file. </li></ul>
    22. 22. <ul><li>PPO application performed on proprietary software platforms </li></ul><ul><ul><li>Setup customized per State for maximum penetration / savings </li></ul></ul><ul><ul><li>Network types: National / Regional / Specialty </li></ul></ul><ul><ul><li>No conflict of interest </li></ul></ul><ul><li>“ Fusion” technology - Competitive Advantage </li></ul><ul><ul><li>Increased savings through multiple network Tiers – Best in Class </li></ul></ul><ul><ul><li>Immediate network application reduces “lag time” </li></ul></ul><ul><ul><li>Increased penetration levels drive additional savings </li></ul></ul><ul><ul><ul><li>Client A has experienced a 58% improvement in PPO Savings </li></ul></ul></ul><ul><ul><ul><li>Client B has experienced a 150% improvement in PPO Savings </li></ul></ul></ul><ul><li>Client specific network solutions on a state-by-state basis through historical data analysis </li></ul><ul><ul><li>Quarterly Reviews of PPO Penetration and Trending Analysis to ensure PPO Tier is appropriate and applicable to current outcomes </li></ul></ul>Network Solutions – The ICS Fusion
    23. 23. PPO/Specialty Savings & Penetration Breakdown <ul><li>Tier 1 % of Total Savings: 29% </li></ul><ul><li>Tier 2 % of Total Savings: 8% </li></ul><ul><li>Tier 3 % of Total Savings: 8% </li></ul><ul><li>Specialty Network % of Total Savings: 22% </li></ul><ul><li>Specialty Review % of Total Savings: 33% </li></ul><ul><li>*Specialty Networks include PT, MRI, DME </li></ul><ul><li>PPO Penetration </li></ul><ul><li>Tier 1 PPO Bill Penetration: 21% </li></ul><ul><li>Tier 2 PPO Bill Penetration: 13% </li></ul><ul><li>Tier 3 PPO Bill Penetration: 9% </li></ul><ul><li>Specialty Network Penetration: 23% </li></ul><ul><li>Specialty Review Bill Penetration: 1% </li></ul><ul><li>Total Bill Penetration: 67% </li></ul><ul><li>PPO Savings </li></ul>Case study: National retail client with warehousing and distribution centers 2009 New Jersey Results: 75% PPO Penetration resulting in 50% Gross Savings
    24. 24. <ul><li>Transparent claimant, provider, and employer tool, customizable by client </li></ul><ul><li>Consolidates all prospective services (pharmacy, PT, imaging, DME) into an ID card </li></ul><ul><li>Created through a claim file feed or in real time through a customized web-site </li></ul><ul><li>Incorporates panels to improve compliance and direction of care </li></ul><ul><li>Increases utilization of prospective programs and PPO penetration, reduces out-of-network management cost </li></ul><ul><li>Enhances quality of care and improve claim outcomes </li></ul>The ICS Health Ticket
    25. 25. IC_Solutions – Specialty Bill Review Services
    26. 26. <ul><ul><li>IC_Solutions offers a suite of services to address the specialty bill review needs of Workers’ Compensation, Auto, Liability, Federal, Longshoreman, and Maritime payers </li></ul></ul><ul><ul><li>These services, supported by innovative and proprietary technology, result in accurate outcomes for Code Review, Desk Audits, and Out of Network Negotiations with Signed Agreements that deliver significant savings to our clients. </li></ul></ul><ul><ul><li>IC_Solution’s experienced subject matter experts have firsthand knowledge of provider billing practices and techniques. </li></ul></ul><ul><ul><li>IC_Solutions Nurse Auditors and Certified Coders prevent overpayment of medical charges </li></ul></ul>IC_Solutions – Specialty Bill Review Services
    27. 27. <ul><li>Code Review - Over $7,750,000 in Savings for CY 2009 </li></ul><ul><ul><li>RN review of coding and supporting documentation </li></ul></ul><ul><ul><li>Review for linkage of Diagnosis Codes to Procedure Codes, along with confirming correct modifier usage </li></ul></ul><ul><li>Desk Audit - Over $3,500,000 in Savings for CY 2009 </li></ul><ul><ul><li>Focused Inpatient Hospital Bill Auditing by experienced Nurse Auditor </li></ul></ul><ul><ul><li>Review for causal relatedness of charges to compensable injury, appropriate length of stay, and appropriate coding </li></ul></ul><ul><li>Out of Network Signed Agreements – Over $3,000,000 in Savings in CY 2009 </li></ul><ul><ul><li>Recommended referral criteria: Any medical bill that comes back without a PPO hit and over $2,500.00 in Charge Amount should be flagged for consideration </li></ul></ul><ul><ul><li>Utilize proprietary application to identify past payment trends to establish appropriate negotiation baselines </li></ul></ul><ul><ul><li>All negotiations are tied to a signed agreement by medical provider to ensure 0% reconsiderations </li></ul></ul>Specialty Review/Negotiated Savings
    28. 28. <ul><ul><li>HIPPO contains information on millions of medical transactions, including costs, charges, PPO hits, and prevailing payments. Queries can be based on individual bills or more globally by using Provider Tax ID Numbers </li></ul></ul>IC_Solutions – Specialty Bill Review Services
    29. 29. <ul><ul><li>Referrals to IC_Solutions for anyone of our services is the model of flexibility, including: </li></ul></ul><ul><ul><ul><li>*Secure E Fax *Secure FTP *EDI *Hardcopy *Email </li></ul></ul></ul><ul><ul><li>The entire body of work for all IC_Solutions services is managed and completed through proprietary web-based case management portal, WebOPUS. </li></ul></ul><ul><ul><ul><li>WebOPUS allows you real-time access to all medical and clinical information associated with a referral. </li></ul></ul></ul><ul><ul><ul><li>WebOPUS allows for secure ongoing communication with the ICS Nurse Auditor and/or Certified Coder on the status and final resolution of a referral </li></ul></ul></ul><ul><ul><ul><li>WebOPUS generates and stores all correspondence, letters, and agreements associated with a referral, easily accessible at anytime. </li></ul></ul></ul>IC_Solutions – How To Refer, Manage, Save
    30. 30. Independent Medical Evaluation & Physician Review Services
    31. 31. Medical Evaluation Services <ul><li>Multi-disciplinary network of Board-Certified physicians </li></ul><ul><li>Providers that maintain an active treating practice with no restrictions </li></ul><ul><li>Medical Evaluation referrals via the internet </li></ul><ul><li>Timely appointments and subsequent appointment management </li></ul><ul><li>Timely receipt of initial and final Medical Evaluation reports </li></ul><ul><li>Thorough quality assurance program to ensure client specific parameters are being met </li></ul><ul><li>Centralized management of referral from start to finish is accomplished via WebOPUS </li></ul><ul><li>WebOPUS Browser available to access real time information, reports, and communications </li></ul>
    32. 32. Independent Peer Review <ul><ul><li>25+ years </li></ul></ul><ul><ul><li>45,000+ reviews performed in 2009 </li></ul></ul><ul><ul><li>National Panel of Reviewers </li></ul></ul><ul><ul><li>URAC IRO accredited </li></ul></ul><ul><ul><li>All lines of business and levels of review </li></ul></ul><ul><ul><li>TAT to meet your business needs </li></ul></ul><ul><ul><li>Dedicated customer service teams </li></ul></ul><ul><ul><li>HIPAA compliant technology </li></ul></ul><ul><ul><li>SAS 70 Type II certified </li></ul></ul><ul><ul><li>Web referrals </li></ul></ul>
    33. 33. <ul><ul><ul><li>National Reviewer Panel </li></ul></ul></ul><ul><ul><ul><li>Over 1,100 reviewers </li></ul></ul></ul><ul><ul><ul><ul><li>All ABMS specialties and subspecialties </li></ul></ul></ul></ul><ul><ul><li>Board-certified </li></ul></ul><ul><ul><li>Active clinical practice </li></ul></ul><ul><ul><li>Current, unrestricted state license(s) </li></ul></ul><ul><ul><li>Well established credentialing committee </li></ul></ul><ul><ul><ul><ul><ul><li>Oversight by MCMC’s Medical Director </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Re-credentialed every three years </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Verification of key credentials </li></ul></ul></ul></ul></ul>Independent Peer Review
    34. 34. Medicare Set Aside
    35. 35. Medicare Set Aside Services <ul><li>Experienced nurses certified in life care planning available to review medical records for : </li></ul><ul><ul><li>Compensable body parts/conditions </li></ul></ul><ul><ul><li>Potential for rated age </li></ul></ul><ul><ul><li>Appropriateness of past treatment/medication use based on clinical practice guidelines and/or ODG </li></ul></ul><ul><ul><li>Compliance with treatment, response to past treatment and recommendations for future treatment </li></ul></ul><ul><ul><li>Pharmacy Benefit Reviews </li></ul></ul><ul><li>Rated age vs. chronological age determines life expectancy on which future costs are based </li></ul><ul><li>Partner with leading law firm to provide legal opinion letter, handle interface with CMS, provide legal support </li></ul><ul><li>Ten Day Turnaround Time </li></ul>
    36. 36. Fraud Abatement & Record Retrieval Services
    37. 37. Fraud Abatement Services <ul><li>National service capability </li></ul><ul><li>Services: </li></ul><ul><ul><li>Mobile and Stationary Surveillance </li></ul></ul><ul><ul><li>Covert surveillance </li></ul></ul><ul><ul><li>Activity checks/neighborhood canvass </li></ul></ul><ul><ul><li>Wellness checks </li></ul></ul><ul><li>Robust quality assurance program </li></ul><ul><li>All referrals and reports/video delivered via the web </li></ul><ul><li>DIGG-IT </li></ul><ul><ul><li>Unique service </li></ul></ul><ul><ul><li>Internet based investigation focusing on the top social networking sites such as Facebook, Myspace, Orkut, Youtube, LinkedIn </li></ul></ul><ul><ul><li>Civil and Criminal History </li></ul></ul><ul><ul><li>E-Commerce sites such as EBay and Craigslist </li></ul></ul><ul><ul><li>Deep Web Research into the interests, lifestyles, and activities of your claimants </li></ul></ul>
    38. 38. Record Retrieval Services <ul><li>National service capability </li></ul><ul><li>Service offering: </li></ul><ul><ul><li>Authorization Procurement </li></ul></ul><ul><ul><li>Subpoena Preparation and Service </li></ul></ul><ul><ul><li>Expedited Service </li></ul></ul><ul><ul><li>Index Hospital Records </li></ul></ul><ul><ul><li>Provider Research </li></ul></ul><ul><ul><li>Copy Records </li></ul></ul><ul><ul><li>X-Ray Duplication </li></ul></ul><ul><ul><li>Record Pick up </li></ul></ul><ul><li>Cost-effective solution to attorney charges </li></ul><ul><li>All services delivered through paralegals and experienced record retrieval staff </li></ul><ul><li>High sense of urgency and industry leading turnaround time </li></ul>
    39. 39. Proprietary Technology – WebOPUS Case Management Portal
    40. 40. Overview of WebOPUS - <ul><li>Robust case management system designed for the proactive case manager that creates bottom line results in today’s competitive industry </li></ul><ul><li>Enables case managers to focus on their patients and provide the most effective oversight by automating their day-to-day tasks </li></ul><ul><li>Structured to integrate all of the Managed Care Services and Activities involved in the continuum of claims management </li></ul><ul><li>An Information Management Tool used to consolidate and coordinate healthcare and claims management activities </li></ul><ul><li>Comprehensive Data Collection and Tracking application </li></ul><ul><li>Flexible rule base logic to provide situation alerts and create triggers to facilitate prompt and effective decision making </li></ul><ul><li>Portal that weaves the data points from all case management activities into one single comprehensive point of entry </li></ul>
    41. 41. WebOPUS Capabilities - Roles Supported <ul><li>Case Manager & Coordinator </li></ul><ul><li>Utilization Review Nurse & Coordinator </li></ul><ul><li>Call Center Care Coordinator </li></ul><ul><li>Review Physician </li></ul><ul><li>Vocational Rehabilitation Specialist </li></ul><ul><li>IME Coordinator </li></ul><ul><li>Claims Adjuster </li></ul><ul><li>Online Approval Adjuster </li></ul><ul><li>Invoice Coordinator </li></ul><ul><li>Nurse Bill Review Auditor </li></ul><ul><li>Network Manager </li></ul><ul><li>Worksite Coordinator </li></ul><ul><li>Support Management </li></ul>
    42. 42. WebOPUS Capabilities - Modules Supported <ul><li>First Report of Injury/Illness/Absence/Accident/Disability Module </li></ul><ul><ul><li>Ability to create new claims for workers’ compensation, auto liability, and general liability </li></ul></ul><ul><li>Service Referral Module </li></ul><ul><ul><li>Ability to create a referral, typically for IME, Peer Review, Desk Audit etc. </li></ul></ul><ul><li>Production Module - Manage Your Worklist </li></ul><ul><ul><li>Primary module. Supports all the various production roles and client and/or industry specific business logic </li></ul></ul><ul><li>Browser Module </li></ul><ul><ul><li>Allows for real time review of cases, documents, notes, treatment plan, return-to-work etc. </li></ul></ul><ul><li>Comprehensive Reporting Module </li></ul><ul><ul><li>Provides for over 25 canned reports available from the Web, ranging from Open Case with Current Lost Time to Timesheet Management Reports. </li></ul></ul>
    43. 43. WebOPUS Capabilities - Core Section Overview <ul><li>Activities Section </li></ul><ul><ul><li>Search and Attach Treating Medical Provider on a claim </li></ul></ul><ul><ul><li>Ability to create Loss Descriptors with ICD-9 codes automatically linked </li></ul></ul><ul><ul><li>Create comprehensive Clinical Treatment & Management Tool </li></ul></ul><ul><li>Notes Section </li></ul><ul><li>Correspondence </li></ul><ul><ul><li>Ability to view, email, and/or fax all of the Documents Received & Created </li></ul></ul><ul><ul><li>Ability to create Standardized and Personal Letter Template Documents </li></ul></ul><ul><li>Claimant </li></ul><ul><ul><li>Summary overview of the demographic and past medical history linked to a claimant </li></ul></ul><ul><li>Treatment Plan </li></ul><ul><ul><li>Summary overview on the Treatment Plan Management and Disability Duration </li></ul></ul><ul><li>Billing </li></ul><ul><ul><li>Ability to view all the Historical and/or Pending bills associated with a claim including EOR, Medical Image and Payment information </li></ul></ul><ul><li>Utilization Review </li></ul><ul><ul><li>Ability to complete a Utilization Review/Pre Cert on all States, including State required Letters & Correspondence </li></ul></ul>
    44. 44. WebOPUS - Browser Tool <ul><li>Facilitates communication with real-time access to user friendly, web-based care management software </li></ul><ul><li>Provides browsers the ability to: </li></ul><ul><ul><li>Follow the medical & disability aspects of cases online </li></ul></ul><ul><ul><li>Review disability guidelines by diagnosis code </li></ul></ul><ul><ul><li>Communicate with nurse case manager online </li></ul></ul><ul><ul><li>Locate medical providers by location/specialty </li></ul></ul><ul><ul><li>Receive auto email alerts of new First Reports of Injuries & Case Management Episodes of Care </li></ul></ul><ul><ul><li>Retrieve Case Management Reports online </li></ul></ul><ul><ul><li>Review the medical payment history on a claim </li></ul></ul><ul><ul><li>Retrieve & Review medical documents attached to a claim </li></ul></ul><ul><ul><li>Generate Management Reports on demand </li></ul></ul>

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