GUIDE TO SELF-FUNDED PRODUCTS & SERVICES FOR EMPLOYERS

Transcription

1 GUIDE TO SELF-FUNDED PRODUCTS & SERVICES FOR EMPLOYERS A Forward-Thinking, Innovative Approach to Helping Employers Manage Employee Benefits While Saving Money Cypress Benefit Administrators

2 CONTENTS What We Believe: Introduction to Cypress Benefit Administrators... 1 The Cypress Solution... 2 Claim Reduction/Elimination Tools... 3 Employee Information/Decision Assistance Tools... 4 Cost Management Tools... 6 Employer Data Management & Information Tools The Bottom Line: Savings Through The Cypress Solution What Happens Next? Plan Administration Conclusion... 14

3 WHAT WE BELIEVE Introduction to Cypress Benefit Administrators Cypress Benefit Administrators has brought together the most technologically sophisticated claim system available, comprehensive cost saving solutions, innovative products and services, and some of the most experienced people in the health care business, all with one purpose in mind: to assist clients in controlling the cost of benefit plans. Cypress was formed in 2000 as a Third Party Administrator to serve the self-funded employer market. At the core of Cypress Benefit Administrators is what we believe. We believe in why we do the things we do, and our relationships and our people, those who stand shoulder to shoulder with us give life to our cause. In everything we do we believe in saving people money, minimizing their risk, and making every interaction with us positive. Top Industry Standards At Cypress, we adhere to a standard of excellence that few other companies can boast. With average client cost increases at 3% or less per year, no other administration company has brought together the tools, the resources, and the expertise quite like Cypress. The company we keep is important as a reflection of who we are, which is why we proudly support the Society of Professional Benefit Administrators, the American Association of Preferred Provider Organizations, National Association of Health Underwriters and the Self Insurance Association of America. Comprehensive Suite of Self-Funded Products & Services for Employers We do everything you would expect a TPA to do, but to be successful means to actually impact the bottom line. To do that, we challenge the status quo and do things other TPAs just don t do or don t even know about! Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 1

4 THE CYPRESS SOLUTION While most companies are quite adept at explaining what it is they do, at Cypress we believe in placing a great deal of emphasis on why we do the things we do. Everything we do has at its base our primary motivation: to assist clients in controlling the cost of benefit plans. Today, Cypress brings to employers the industry s most comprehensive set of administration, service, cost control, wellness and data management tools through THE CYPRESS SOLUTION. No other administrator has brought together the best-in-class vendors, software, programs, innovation and minds and made them available in one solution. In order to achieve real, measurable results, The Cypress Solution focuses on four key areas: Claim Reduction/Elimination, Employee Information/Decision Assistance, Cost Management and Employer Data Management and Information. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 2

5 The Cypress Solution: CLAIM REDUCTION / ELIMINATION TOOLS Reducing and/or eliminating the number of claims through assessments and advocacy Cypress Benefit Administrators offers a number of tools to help employers positively control the number of employee health plan claims. Our tools include: Wellness Programs (Thrive), On-Site Medical and Disease Management. WELLNESS The need to identify the highest risk people on your plan is obvious. Getting the at-risk population healthy and keeping the healthy population in their current state is equally obvious. Many employers are turning to wellness plans as the answer. Cypress Benefit Administrators has put together one of the most comprehensive wellness programs in the industry: Thrive. Components of Thrive On-site HRA (Health Risk Assessment) with published results Professional Coaching & Follow Up Positive incentives to get and stay healthy Access to information for the consumer On-Site Medical Disease Management Medical Advocate Program Employee incentives for participation & health improvement ON-SITE MEDICAL Employers can now control how and when employees access primary care. With on-site medical solutions, employers can monitor and incentivize employees to receive preventive care services without having the leave work. DISEASE MANAGEMENT The need to identify the highest risk (and therefore most expensive) people covered under the plan, and managing their diseases, is of the greatest importance to an employer paying for health benefits. The CYPRESS SOLUTION DISEASE MANAGEMENT PROGRAM offers a unique, multi-layered approach aimed at finding and managing the diseases that are specific to the employer. High-Risk Disease Management is designed to make an impact on the sickest members of a plan; Population Disease Management makes an impact on all chronically ill individuals enrolled; Total Health Management manages all individuals covered under the plan to get the highest risk and chronically ill people well, and gives education tools to keep the well people well. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 3

6 The Cypress Solution: EMPLOYEE INFORMATION / DECISION ASSISTANCE TOOLS Making employees active participants in the decision-making process Providing employees with the opportunity to make appropriate and informed decisions about their health care options is a critical piece to assure that they are receiving necessary care in the appropriate setting with the highest quality providers nationally. Cypress offers a number of tools to help employers offer that involvement to their employees. Our tools include: Cypress Online Medical Advocacy Medical Tourism Telephonic Physician Consultation Consumer-Driven Health Plans CYPRESS ONLINE Cypress Online is a set of E-Services designed specifically for the needs of Cypress clients and their employees. Services are designed to connect your employees directly with their health benefits. With Cypress Online, your employees can access their own benefits information from anywhere at any time via the internet. Questions get answered more quickly with fewer phone calls, less paperwork and better results! Available services include: Online Enrollment Online Claims Payor Announcements Online Customer Service/Express Requests Documents and Links Notifications Medical Search Engine MEDICAL ADVOCATE PROGRAM Seeking care is a scary experience, and potentially very dangerous. The statistics are startling, suggesting that patients leave physicians offices not knowing what to do next, more than half the time choosing the wrong type of specialist. Making the wrong choice generates on average $3,500 in extra, unnecessary costs. Picking doctors at random is dangerous and costly, which is why employees so desperately need an advocate to help guide them through the medical maze. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 4

7 Cypress medical advocacy programs offer employees the guidance they need. The program talks with patients before care is rendered, focusing on the quality of care, communicating medical alternatives and differences in costs, and profiles the best care givers for a patient s specific procedure in their area. Medical Advocacy is a trustworthy source to help employees make the right decisions, saving employers money. MEDICAL TOURISM Opening up the entire country to gain efficiencies, obtain the highest quality of care, and drive down the cost of care is steadily becoming a cornerstone of employer cost containment strategies. When employees travel for care and surgeries, they receive the best possible treatment available anywhere in the country, which improves outcomes and morale, and employers save money. When coupled with predictive modeling, the program becomes proactive; identifying high risk patients and working with them to engage the program. TELEPHONIC PHYSICIAN CONSULTATION Most ER visits and trips to Urgent Care could be prevented using a telephonic doctor consultation program. With 24/7, around the clock access, anytime, anywhere and on holidays employees have access to visit with licensed physicians who can diagnose and prescribe medicine right over the phone. CONSUMER DRIVEN HEALTH PLANS Cypress Benefit Administrators is a pioneer in Consumer Driven Health Plans, having introduced CDHP to clients in Programs include: HRA and HSA Administration Plan Design Consulting Wellness Programs Informational Tools Cypress Online Decision Support/Medical Advocacy Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 5

8 The Cypress Solution: COST MANAGEMENT TOOLS Monitoring claims carefully and managing costs when they are incurred In order to control health care costs, employers must have access to state-of-the-art Cost Control and Medical Risk Management Tools. Cypress has the widest array of cost control programs available in the industry. Our tools include: Claim Administration Fraud & Abuse Detection (Argus Claim Review) Pharmacy Cost Management Organ Transplant Carve-Out Next-Generation Cost Control Programs Dialysis Cost Control Network Management Active & Passive PPOs Medicare-Like Repricing CLAIM ADMINISTRATION Cypress Benefit Administrators offers complete claims administration services. Our accuracy and customer service performance are very highly rated, as shown below: Claims Financial Accuracy 99.5% Average Claims TAT* days Claims TAT* Within 10 days 78.2% Within 15 days 88.5% Within 30 days 95.9% Customer Service Average speed to answer calls (seconds) Claims 7.5 Group Admin 6.7 Provider Relations 18.5 First-Call Resolution 92.9% Frequency of Calls Rec Busy Signal 0 Statistics shown above are year-to-date as of November *Claims TAT: Measured from date claim received to date benefits are paid, a denial letter is sent or the claim is set aside pending additional information. FRAUD & ABUSE DETECTION There is $250 Billion in annual waste in health care. Much of the waste comes from fraudulent billing, creative billing schemes, claim system deficiencies and lack of good data to identify areas of waste. Cypress Benefit Administrators has changed the dynamic, bringing together the most comprehensive and far-reaching fraud detection, medical risk management and code editing program in the industry. Provider Integrity Programs Data driven, provider centric fraud prevention with over 12,000 provider identification numbers on our watch list Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 6

9 Mine and manage over 1,100 data sources 35,000+ HHS sanctions 40,000+ high risk addresses Automated FSA Deathmaster matching Patriot Act compliance Identifies providers with a track record of aberrant billing practices and/or positive investigations experience before claims are paid Relevant Statistics: - 3.4% of all provider records in the US are phantom providers $.10 of every dollar spent in health care is fraud or abuse (NHAA) Average savings of 54% for every dollar reviewed Intelligent Claim Surveillance Pattern recognition: Identifies sophisticated schemes by integrating statistical models with historical claim patterns to score the probability of fraud or abuse. Technology originally used for the credit card industry. Uses historical data to develop profiles and constantly updates the data to learn and detect both known and emerging fraud schemes. Claim line analytics rank claims according to fraud risk with reason codes to quickly pinpoint claims that warrant review on a prepayment basis. Automated Code Edits 11 Rule Modules to detect and prevent abusive billing practices on a prepayment basis (rebundling, CPT Add-on codes, Incidental procedures, Problematic coding, Global surgical, E-M Crosswalk, Modifier Misuse, Medical necessity, Asst. Surgeon inappropriateness, New patient visit levels) 300,000+ rule, comprising over 15 million sourced and documented edits from CMS, AMA, CCI, and Professional Medical Associations Provider Variance reporting facilitates network management Claims are properly coded PRIOR to PPO repricing Pre-Payment Investigations Daily Claim file analyzed for provider matches and fraud risk scores Daily Queues created and worked by investigative staff to focus efforts on best opportunities for pre-payment investigations 24 Hour claim decision turnaround (pay, deny or hold for further info) Investigations Include: License verification, Patient Interview, Document Analysis, Medical Record Review, Clinical Review, Coding review Experienced, Multi-Disciplinary staff including special investigators experienced in health care fraud, clinical staff and coding professionals 54% Average Savings in every dollar investigated Fraud awareness training and compliance for all 50 States Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 7

10 PHARMACY COST MANAGEMENT Cypress Benefit Administrators works with a variety of pharmacy benefit management organizations to ensure that employers are getting the best possible discounts, access and service at the best possible price. This innovative program also includes BidRx/PartnersRx a one-of-a-kind partnership that can save consumers up to 85% on prescription drug costs. With any of our pharmacy programs, employers can expect to work with aggressive formulary structures and unique cost-saving programs like mandatory generic utilization, therapeutic subbing and tablet splitting programs. Using this approach, clients will save money and minimize rebate dollars by avoiding high-cost drugs. ORGAN TRANSPLANT CARVE-OUT INSURANCE Organ Transplants are one of the most expensive procedures an employer can cover under its benefit plan. Cypress Benefit Administrators offers clients the opportunity to totally eliminate the risk of paying for organ transplants through its organ transplant carve-out plan. A stand-alone, fully insured, first-dollar product that is designed specifically for self funded groups; Works in conjunction with an employer s plan by carving out the transplant benefit and insuring it separately from the plan document; Protects the employer from catastrophic expenses of transplant exposures; Attaches to any plan document, regardless of the stop loss carrier Pays 100% of all major transplant types and their related costs Stop Loss insurance often does not pay for transplant exposures due to lasers and many carriers will offer significant premium discounts when a carve-out program is purchased. Additionally, having an insured program eases the cash flow issue of having to pay for a highly expensive transplant procedure. NEXT-GENERATION COST CONTROL PROGRAMS The key to any successful self-funded program is the ability to prevent and manage plan costs to the extent possible. Many tried-and-true methods to contain costs continue to work today, but innovative outside-the-box thinking will enhance and promote savings opportunities. Cypress has and will continue to deliver innovative and evidence-based solutions to our clients through state-of-the-art programs like predictive modeling using proprietary algorithms, medical tourism, on-site medical programs, telephonic and web-based doctor consultations, and patient advocacy programs. DIALYSIS COST CONTROL Dialysis costs continue to rise at a nearly exponential rate, oftentimes ending up being the single most expensive item in a medical spend budget. With costs averaging $50,000 per month or more, the need for a program that specifically addresses the costs and care associated with the treatment of renal disease has never been greater. With our programs, employers can expect to save money on the cost of Epogen, and our specific case management system will educate patients on how to dialyise at home, which leads to better patient outcomes and lower costs. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 8

11 NETWORK MANAGEMENT The Cypress approach to PPO network placement and access to network doctors is truly unique to the industry. Where most administrators choose a primary network access point and then select a national wrap network for travel and out-of-network situations, Cypress uses a matrix approach where a series of best-in-class regional networks are utilized. This approach will allow a member to see a true innetwork provider anywhere they may travel or conduct business, which leads to greater savings and positive member experiences. ACTIVE AND PASSIVE PPOs Cypress works with Primary PPO programs that offer employers in-network provider discounts when proper employee incentives are in place in the plan design. In addition, Cypress utilizes Passive PPO programs that give access to discounts even when employees don t use in-network providers. Achieves discounts on 72% of retail claims for out-of-network providers at an average discount of 26%; Allows access to over 140 PPOs nationwide with more than 650,000 providers. MEDICARE-LIKE REPRICING For true outside-the-box-thinking clients, Cypress offers a program that will replace the traditional PPO structure for that of a repricing methodology that is based on how Medicare reimburses providers. Still in its relative infancy, Medicare-like repricing is growing in its effectiveness as providers are held to a truly discernible benchmark and are prompted to substantiate their charges as fair. In some situations, clients can experience savings of 80% or more off the cost of billed charges. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 9

12 The Cypress Solution: EMPLOYER DATA MANAGEMENT & INFORMATION TOOLS Tracking plan effectiveness and making adjustments as necessary Cypress provides multiple information sources and analytical tools to employers and employees. Armed with information (not just data), important decisions can be made about the direction of an employer s benefit plan. Given access to critical information about their plan, consumer options and providers, employees can make important decisions about where and how they will receive health care services. Our tools include: Monthly Reports Client-Specific Reports Cypress Online Plan Modeling Predictive Modeling Medical Advocacy Provider Quality Measures THE BOTTOM LINE Savings Through The Cypress Solution No single Administrator has put together Cost Saving Tools, Excellent Claim Administration, Responsive Customer Service, Creative Consumer-Driven Health Plans and Advanced Reporting Capabilities until NOW! Financial Impact Area Savings Provider Integrity/Fraud Prevention 1-2 % Intelligent Claim Surveillance 1-4 % Pre-Payment Investigations 1-3 % Provider R & C Negotiations 1-3 % Passive PPO Access 2-4 % Large Claim Auditing 2-4 % + Organ Transplant Carve Out 7-10% (on Stop-Loss) Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 10

13 WHAT HAPPENS NEXT? Plan Administration Implementation The success of a self-funded healthcare plan begins with an effective transition from the current claims administrator. In order to ensure a smooth implementation, Cypress Benefit Administrators will coordinate an installation meeting upon our selection as the plan TPA. This meeting will be conducted by a Cypress representative with members of the Human Resource and Finance staff of the client, the company s insurance agent and other company appointees as appropriate. At this initial meeting, all administrative details are addressed. Such issues as enrollment, banking, stoploss insurance protection, plan design, claim forms, utilization management and PPO networks are discussed in detail. A timeframe is established for completion of all necessary aspects of the implementation. A day period is the most desirable timeframe for a complete and effective installation. However, Cypress will work to do the installation in whatever time frame is necessary. Cypress Benefit Administrators will have a single liaison for the tasks outlined above. Additionally, all appropriate personnel at Cypress will be intimately involved in the development of materials to ensure clear communication of the program to employees and to assure a smooth transition. Claim Administration Each client will have a dedicated claims analyst (or analysts, where necessary, dependent on client size) to handle all claims for that client. The analyst will be the single point of contact for all claim inquiries from employees. Processing goals are 98.5% procedural accuracy and 99.5% financial accuracy. In addition to these very high accuracy standards, Cypress Benefit Administrators maintains a 7-day turnaround from the time a clean claim is received until it is processed. Member Services The client s individually assigned Claim Analyst handles all eligibility and claim inquiries from employees, employers, and providers. The analyst is available to receive telephone inquiries Monday through Friday, 8:00 AM to 5:00 PM. After hours inquiries can be made by leaving a voice message and the analyst will return the call with an answer by noon the next working day. All Analysts go through comprehensive claims training in addition to customer service training. This allows them to answer all types of inquiries (i.e., benefit questions, claims issues, enrollment and PPO issues). The Analysts have access to eligibility and claims history. A Customer Service database is used to log all calls, from which Cypress Benefit Administrators will be able to produce reports showing the number and types of calls that are received as well as the resolution to the inquiries. The management staff of the department monitors call activity to assure timeliness. A monthly audit is conducted for call quality, to ensure accuracy of response. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 11

14 Subrogation For subrogation services, Cypress Benefit Administrators has contracted with The Phia Group to represent clients in subrogation negotiations. The Phia Group will charge no upfront fees, but will charge the client 33% of the documented savings generated through its successful efforts to negotiate subrogated claims. Reporting All plan data is compiled and provided to the client through a series of standard monthly reports. These reports are posted to a secure FTP site within two weeks of month's end. Additionally, Cypress Benefit Administrators will provide specialized reports as requested. Many special reports are provided at no additional cost. However, Cypress reserves the right to charge its normal fee of $125 per hour, if custom programming or reporting is required. Banking Cypress suggests that a zero balance checking account be set up at the bank of the client's choice. Although this is the preferred banking arrangement, Cypress Benefit Administrators is able to handle multiple banking options. The banking arrangements will be agreed upon during the installation meeting. Account check registers sorted by check number will indicate paid transactions and will be issued weekly, or as agreed upon during the implementation meeting. All transactions paid during the month will be compiled and furnished to the client on the Monthly Paid Claims Report. Upon transmittal to Cypress Benefit Administrators of the monthly account statement and electronic or tape transmittal of cleared checks from the bank, an outstanding check report will be provided. If desired by the client, Cypress can provide monthly account reconciliation for an additional fee. COBRA Administration The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that employers with twenty (20) or more employees offer continued health coverage to employees and their eligible dependents who lose their coverage due to certain qualifying events. To ease the time-consuming, labor-intensive burden that COBRA can present to the employer, Cypress Benefit Administrators offers a COBRA Administration Program. Upon notification of a COBRA election, Cypress will confirm and track COBRA participants throughout their 18, 29 or 36 months of continued coverage, monitoring continued eligibility. Cypress will supply participants with payment coupons and collect all premium payments, providing comprehensive reporting on a monthly basis. Additionally, Cypress will communicate issues such as eligibility, plan benefit or premium cost changes, and termination notification to the COBRA participant. Flexible Spending Account Cypress Benefit Administrators Healthcare Reimbursement Account Programs allow your employees to contribute pre-tax dollars each pay period for non-covered Medical and Dependent Care expenses. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 12

15 The administration of your Healthcare Reimbursement Accounts and Dependent Care Reimbursement will include the processing of election forms, enrollment changes, and terminations. Our Flex Unit will also be responsible for the posting of payroll contributions and the prompt issuing of reimbursement checks. Detailed reporting will be supplied to you on a monthly basis and to your employees quarterly. Prescription Drug Card Benefit Cypress Benefit Administrators will provide administration of the Prescription Drug Card Benefit and coordinate with the selected Prescription Benefit Manager (PBM) on eligibility, billing and claim payment functions. Preferred Provider Organization Coordination If a PPO is chosen, Cypress will pay claims according to the discounts and fee schedules negotiated by the PPO. Cypress has access to national and regional networks across the country that can be utilized as needed. Preferred provider fee schedules are maintained in the Cypress Benefit Administrators computer system. Integration with our claim system will assure efficient claims payment and prompt turnaround time. There are, however, some PPOs that require their involvement in repricing claims prior to adjudication by Cypress. In that event, Cypress makes every effort to expedite the repricing process so the claim can be adjudicated on a timely basis. Turnaround time for repricing varies by PPO and should be a consideration for an employer when choosing a PPO with which to contract. Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 13

16 CONCLUSION Thank you for your interest in Cypress Benefit Administrators. We believe that our product offerings including claim administration, service, cost control programs, wellness and information are unique. We look forward to the opportunity to work with you in developing a successful, efficient and costeffective benefits strategy and package to fit the needs of your business and its employees. To get started or learn more, contact us via (cypressmarketing@cypressbenefit.com) or at Respectfully, Cypress Benefit Administrators, LLC Guide to Self-Funded Products & Services for Employers Cypress Benefit Administrators 14