Healthcare Services Division
Healthcare Payer Services
Corporate Profile
TBS – Healthcare Services
Payer Services
Healthcare - Payer Services
Enrollment & Eligibility Management
Claims Management
Payment Integrity Audit services
‣ Overpayment Recovery
‣ DRG Compliance Audit
Key Differentiators
Value Proposition
Contents
Corporate Profile
Inception
Global Delivery Centers
Clients profile
Service Portfolio
Data Security
Quality
Delivery
Founded in 2006; headquarters in NY
Near shore and Off Shore delivery centers, Headquarters based in NY and delivery centers in both US and India
Clients range from Small entities to Fortune 100 organizations
HealthCare & Insurance – Payer & Provider services
ISO/IEC 27001:2005 (BS 7799 - Information Security Management System [ISMS] Certified) security standards.
HIPAA Compliant Organization
Six Sigma based methodologies for Transition, Quality & Process efficiency & LEAN programs for process improvements
Global Delivery Model, which delivers 24 X 7 services
TBS-Healthcare Services
FEATURES
• End-to-end services on both the Payer & Provider domains
• Expertise spanning the entire gamut of services ranging from simple transaction based services to
high-end audit, research & analytics.
• Proficiency in niche segments such as Payment Integrity Audit, Claims Administration, Code
Review Audit, DRG Audit etc.
TBS - Payer Services
Enrollments - New Enrollments
& updates maintenance
Eligibility Management
Pre-Ex & COB information
verification
POLICY ADMINISTRATION
Out-of-Network Claims Negotiation
Support
Provider Contracting
Contract Maintenance
NETWORK MANAGEMENT
Provider updates & Data
maintenance
Facility Data maintenance
Manual Provider matching
Provider Credentialing Support
PROVIDER DATABASE MANAGEMENT
Claims Data Entry
Pre-Adjudication
Claims Adjudication services
International, RX & CDH claims
processing
Claims Re-pricing
Claims Adjustments
CLAIMS MANAGEMENT
Physician Referral review process
Pre-auth generation
Inpatient Admission notification
UTILIZATION MANAGEMENT
Payment Integrity Audit
(Overpayment Recovery) Services
Claims Reconsideration
Hospital Bill Audit
Code Review & DRG Audit
PAYER ANALYTICS
Our current experience in the Payer domain comprises of service
offerings in the following process areas
Eligibility & Enrollment Management
FEATURES
6 years of experience in Enrollment services for a TPA.
TBS handles the following as part of Policy administration:
New enrollments
Changes
Run-in plan inclusions
Terminations
Member Eligibility Verification, as an allied function of Overpayment Recovery
Services verifying the Medicare/Commercial eligibility for members
Determination of primary & secondary claim payment responsibilities
Source data to establish if the member has any other insurance coverage
Identify overpayments due to incorrect co-ordination of benefits between primary &
secondary insurers
Dependent Eligibility Audit to identify ‘ineligible’ dependents, vis-à-vis the plan’s
eligibility requirement
Value Proposition-Member Enrollment & Eligibility
Business
Process
Claims Management Services - Overview
TBS currently offers the following services within the Claims / Revenue Management services, on the Payer side.
TBS users login remotely to the client servers, through a secure connection, & access the data needed to perform
the various functions.
Value Proposition – Claims Adjudication
- Resource optimization through
strategic utilization of internal
resources
- Prevention of possible over
payments & first level claim appeals
- Operational cost savings in the
range of 30-50%, on existing costs
- 60% reduction in training costs
- Plan & prioritize the claim volume
to coincide with scheduled check-
runs
- Flexible operations to meet urgent
requirements
- Faster Turn around times
(improvement of over 33% )
- Higher accuracy rates (exceeding
99% on financial & 98% on
procedural accuracy)
Adjudication
Business
Process
Payment Integrity Audit Services-Overview
TBS currently offers a comprehensive suite of Payment Integrity Audit services.
Overpayment Recovery Services- OverviewSNAPSHOT
Experience in the Overpayment Recovery Services for a leading national insurer – includingclaims review as 2nd or 3rd pass vendor
Identified over $200 Mm for our partner, of which approximately 60-70% of the overpayments($125 - $150 Mm) were identified as part of 2nd/3rd pass review
Reviewed & analyzed 200,000 claims per year, and identified overpayments resulting fromincorrect contractual reimbursement, billing & coding discrepancies and incorrect co-ordination of benefits
Overpayment ratios of 8-10% in professional claims & 5-7% of institutional claims
Overpayments ranging from $50 to $5,000 (Professional claims) & $1,000 to $500,000(Facility claims)
APPROACH & METHODOLOGY
Comprehensive 360 degree analysis covering aspects of Bill review, Code review, DRG review,Contractual reimbursement & Coordination of Benefits
A dedicated team to identify low $ refunds, which would not have been cost-effective for theonsite analysts
Identification of fraudulent & abusive provider practices, resulting in claim overpayments
Trained and certified work force that comprises of qualified Medical Doctors and CertifiedMedical Coders
Overpayment Recovery Services – Process FlowTBS endeavors to maximize overpayments’ identification through optimized efforts. We
partner with our clients to combine robust data mining techniques with deep domain
analysis, to achieve this objective.
• Process
Migration
• System
Training
• Process
Documentation
& Client sign-
off
Knowledge
Transfer
• Data feed of
paid claims
• Data Mining &
retrieval
• Claims
segregation &
prioritization
Data
Analysis
• Analysis of
paid claims
• Identification
of over-
payments
• QA process
Claims
Audit
• Provider
Contact -
Recoupment
(Offsetting
future
payments)
• Provider
follow-up &
recovery
Overpayment
Recovery
DRG Compliance Audit
Approach & Methodology:
360 degree retrospective review of claims, going beyond tool based insights &
predictive analytics, augmented by ‘deep-dive’ manual analysis
Medical Code Editor (MCE) support to review medical records for compliance
Data quality reviews on inpatient records to validate the ICD-9-CM codes, DRG
group appropriateness, missed secondary diagnoses and procedures, and ensure
compliance with all DRG mandates and reporting requirements
Continuous evaluation of the quality of clinical documentation
Review of medical records & corresponding documentation for completeness,
accuracy and compliance
Recommendations for revised DRG assignment, supported by medical records
Review of
Medical
charts
Research &
Analysis
Summary of
Audit
findings
Provider
Education
Value Proposition – Payment Integrity Audit
Business
Process
Healthcare - Key Differentiators
A decade of proven service track record
End-to-end expertise on Payer and Provider domains
Expertise spanning across the value chain rangingfrom low-end transaction services to high-end audit &analytical services
Thorough understanding of the claim life cycle,enabling us to understand the nuances of ClaimsManagement
Experience & expertise in the niche segments of CostContainment, Out-of-Network Claims settlement &Pharmacy benefits domains
Experienced staff comprising of certified analysts &Professional Medical doctors as DRG coders
Customer satisfaction through our ability tothoroughly understand the client businessrequirements and highly effective delivery capabilities
High client retention ratio
Identified overpayments of over $200Mm, as part of our Payment Integrity Audit services
Identified recurrent patterns in provider billing resulting in overpayments of over $7.5 mm , in the
NICU claim scenario
Discovered uncharted claim scenarios for billing & coding inconsistencies in Mental health, and
Dialysis claims (Epogen & Epoetin administration)
Achieved cost savings of over 40% & Improvement in TAT of 33% on existing parameters
Benefits to Clients
Value Proposition
Value Proposition
Revenue enhancements & cost optimization
Improve Billing & Coding compliance
Identify fraudulent billing/coding practices & prevent wasteful expenditure
Experience in the Payment Integrity Audit services, recovering overpayments of over $200 Mm
Comprehensive domain expertise spanning the entire spectrum of Payer-Provider services
PROCESS
ENHANCEMENTS
BUSINESS
PROCESS
OPTIMIZATION
CROSS
FUNCTIONAL
EXPERTISE
Redefining Business Approach
Building Relationships
Learning Together
Knowledge Management
Process Improvements
Productivity Gain
Performance and Profitability
Organizational Fit
Openness and Accountability
Ownership and Responsibility
BEST
POSSIBLE
OPTION
Building RelationshipsLearning TogetherKnowledge Management
Contact me today to find out how TBS and
our solutions can improve your bottom line
with no upfront fees!
Tim Kirsch
Consulting Partner
Transnational Business Solutions, LLC
45 West 34th Street Suite 1107
New York, NY 10001
800-362-8691