TBS Over payment Recovery Services for Health Insuers

1. Healthcare Services Division
Healthcare Payer Services

2. Contents
 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

3. 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

4. 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.

5. TBS - Payer Services
Our current experience in the Payer domain comprises of service
offerings in the following process areas
POLICY ADMINISTRATION
 Enrollments - New Enrollments
& updates maintenance
 Eligibility Management
 Pre-Ex & COB information
verification
NETWORK MANAGEMENT
 Out-of-Network Claims Negotiation
Support
 Provider Contracting
 Contract Maintenance
PROVIDER DATABASE
MANAGEMENT
 Provider updates & Data
maintenance
 Facility Data maintenance
 Manual Provider matching
 Provider Credentialing Support
CLAIMS MANAGEMENT
 Claims Data Entry
 Pre-Adjudication
 Claims Adjudication services
 International, RX & CDH claims
processing
 Claims Re-pricing
 Claims Adjustments
UTILIZATION MANAGEMENT
 Physician Referral review process
 Pre-auth generation
 Inpatient Admission notification
PAYER ANALYTICS
 Payment Integrity Audit
(Overpayment Recovery) Services
 Claims Reconsideration
 Hospital Bill Audit
 Code Review & DRG Audit

6. 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

7. Value Proposition-Member
Enrollment & Eligibility
Business
Process

8. 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.

9. Value Proposition – Claims Adjudication
Business
- 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
Adjudication
- 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)
Process

10. Payment Integrity Audit Services
-Overview
TBS currently offers a comprehensive suite of Payment Integrity Audit
services.

11. Overpayment Recovery Services
- Overview
SNAPSHOT
 Experience in the Overpayment Recovery Services for a leading national insurer – including
claims 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 from
incorrect 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 the
onsite analysts
 Identification of fraudulent & abusive provider practices, resulting in claim overpayments
 Trained and certified work force that comprises of qualified Medical Doctors and Certified
Medical Coders

12. Overpayment Recovery Services
– Process Flow
TBS 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
Analysis
• Data feed of
paid claims
• Data Mining &
retrieval
• Claims
segregation &
prioritization
• Analysis of
paid claims
• Identification
of over-payments
• QA process
Claims
Audit
Overpayment
Recovery
• Provider
Contact -
Recoupment
(Offsetting
future
payments)
• Provider
follow-up &
recovery

13. DRG Compliance Audit
Review of
Medical
charts
Research &
Analysis
Approach & Methodology:
Summary of
Audit
findings
Provider
Education
 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

14. Value Proposition – Payment Integrity Audit
Business
Process

15. 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 ranging
from low-end transaction services to high-end audit &
analytical services
 Thorough understanding of the claim life cycle,
enabling us to understand the nuances of Claims
Management
 Experience & expertise in the niche segments of Cost
Containment, 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 to
thoroughly understand the client business
requirements and highly effective delivery capabilities
 High client retention ratio
Benefits to Clients
 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

16. 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

17. 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

18. Contact me today to find out how TBS and
our solutions can improve your bottom line
with no upfront fees!
Building Relationships
Learning Together
Knowledge Management
Tim Kirsch
Consulting Partner
Transnational Business Solutions, LLC
45 West 34th Street Suite 1107
New York, NY 10001
800-362-8691
tkirsch@transbizsolution.com