HEALTH Claim COST CONTAINMENT SOLUTIONS for Tpa

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HEALTH ClaimCOST CONTAINMENT SOLUTIONS for Tpas

• Presented
• by
• London Medical Management, Inc.

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DISCUSSION

• Health Claim Cost Containment Solutions
• Unique combination of Health Claim Negotiations
  with PatientPALTM advocacy services

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• HEALTH CLAIM NEGOTIATIONS
• 2 Buckets of Claims

• In-network Claims
• PHCS
• Multi-plan
• Three Rivers
• InterPlan
• Beech Street

• Out-of-network Claims
• No network affiliation
• No discounts

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• HOSPITAL STOP LOSS PROVISION
• Protects the Hospital, NOT the Client

Day 1 2 3 4 5 6
Billed Charge 12,000 24,000 36,000 48,000 60,000 72,000
Per Diem 1,500 3,000 4,500 6,000 7,500 9,000
Payment to Hospital 1,500 3,000 4,500 6,000 36,000 43,200
Once Billed Charges reach the Stop Loss amount
(50,000 in this case), hospital Reimbursement
reverts from Per Diem to a Percentage of Billed
Charges (usually 40 discount) Example above
Average Daily Reimbursement is 7,200
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• HEALTH CLAIM NEGOTIATIONS
• 2 Buckets of Claims

• In-network Claims
• PHCS
• Multi-plan
• Three Rivers
• InterPlan
• Beech Street

• Out-of-network Claims
• No network affiliation
• No discounts

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• HEALTH CLAIM NEGOTIATIONS
• Process

• Pend
• ALL in-network claims that reach 10,000
  level
• ALL out-of-network claims
• All Claims must be pended BEFORE they are paid
• Threshold levels may be adjusted to maximize
  client savings

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• HEALTH CLAIM NEGOTIATIONS
• Process

• CLAIM from TPA
• UB 92/HCFA 1500
• ASC II File Format
• In/Out of network
• indication

• Provider Contact
• agreements are negotiated one
• claim at a time

• Provider Charges (Research)
• based on geographic
• location of the facility/provider
• - Historical negotiations data

• LMM Claim Fact Sheet
• claim details extracted
• from info provided by
• TPA

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• HEALTH CLAIM NEGOTIATIONS PROVIDER DATABASE

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• HEALTH CLAIM NEGOTIATIONS
• Claim Fact Sheet

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• HEALTH CLAIM NEGOTIATIONS
• Claim Fact Sheet

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• Claim Negotiations Protocol

• In-network Claims
• Claims lt 10,000 should be processed
  according to
• the network contract
• Claims gt 10,000 will be sent to LMM for
  review
• Out-of-Network Claims (include wrap networks)
• ALL out-of-network claims will be sent to LMM
  for review
• Threshold levels may be adjusted to maximize
  client savings

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Facility State Billed Charges PLAN Allowable Final Negotiated Pmt LMM Client Savings LMM PLAN Savings
AR 37,056.99 37,056.99 10,500.00 26,556.99 26,556.99
IN 171,707.02 171,707.02 111,609.56 60,097.46 60,097.46
AR 24,737.00 22,602.00 18,609.64 3,992.36 6,127.36
OH 23,135.00 23,135.00 18,508.00 4,627.00 4,627.00
IN 59,961.87 47,969.50 38,975.22 8,994.28 20,986.65
FL 25,702.00 25,702.00 21,846.70 3,855.30 3,855.30
AR 26,580.92 21,008.64 10,000.00 11,008.64 16,580.92
IN 12,477.11 12,477.11 6,000.00 6,477.11 6,477.11
AR 35,930.19 23,354.62 20,000.00 3,354.62 15,930.19
AR 11,083.00 11,083.00 6,500.00 4,583.00 4,583.00
AR 18,340.00 18,340.00 10,000.00 8,340.00 8,340.00
AR 13,588.80 13,588.80 8,200.00 5,388.80 5,388.80
IN 24,318.00 24,318.00 20,670.30 3,647.70 3,647.70
PA 10,220.60 10,220.60 9,198.54 1,022.06 1,022.06

TOTALS 494,838.50 462,563.28 151,945.32 184,220.54
32.85
Additional savings
Negotiations for a Fortune 500 company working
with a nations leading health plan PLAN
Allowable includes discounts available through
associated networks
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Nationally recognized advocacy service for your
clients
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• PATIENT PALTM

• Patient PAL is an advocacy service available to
  employees and their covered family members when
  faced with
• Chronic health conditions
• Emergencies
• Major surgeries
• High-risk critical illnesses
• Catastrophic health events

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• Patient PAL Care Continuum

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• Electronic Medical Record (EMR)

Patient Record Face Sheet
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• Patient Referral Source

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• London Medical Management
• Contingency Fee

• Health Claim Cost Reduction
• Percentage of documented savings
• Patient PAL services available to all covered
• members on as needed basis

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WHAT WE HELP YOU ACHIEVE

• Decrease the total cost of health care through
  direct negotiations of individual patient claims
• Enhanced service by accessing Patient PAL for
  employees makes TPAs more competitive against
  carriers

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Our Value Proposition

• We assist TPAs and employers to reduce the cost
  impact of large claims through direct
  negotiations with providers. We utilize the
  savings from these negotiations to help employees
  and their dependents navigate the complexities of
  the healthcare system through our Patient PAL
  program.

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• Our Clients Include

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SUMMARY

• Health Claim Cost Containment Solutions
• Unique combination of Health Claim Negotiations
  with Patient PALTM advocacy services

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NEXT STEPS

• Implementation
• Business Associate Agreement between TPA and LMM
• Claims negotiation protocol implementation with
  the Health Plan
• Non-disclosure Agreements

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Frequently Asked Questions

• Q How are negotiations done?
• A Knowledge-based negotiations with information
  available through internal negotiation database.
• Q Is existing discount negated?
• A Existing discount is never negated. Thats why
  allowable amount is critical to have so that LMM
  negotiates an additional
• discount.
• Q Who pays LMM fees?
• A Client pays LMM fees.
• Q What is the provider payment monitoring
  system?
• A Once negotiations are complete LOA is sent to
  client TPA for payment LMM reaches out to
  provider to verify receipt of
• payment.
• Q How is the claim information exchanged?
• A Excel format, usually exchanged through
  clients FTP/secured server.
• Q How often is client invoiced?
• A Monthly

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Frequently Asked Questions

• Q What is included in the invoice?
• A All negotiated claims showing Billed Charges,
  Allowable, Final Payment and Savings.
• Q How long is the set-up process?
• A Usually two weeks from signature of all
  agreements.
• Q Is Allowable or Payment negotiated?
• A Negotiations are based on Allowable amounts.
• Q What happens to patient responsibility,
  deductible and/or co-insurance upon successful
  completion of
• negotiations?
• A Patient responsibility still applies.
• Q What are the next steps?
• A Health Plan LOI BAA Contract with LMM
  analysis of health claims retrospectively to show
  potential
• savings had LMM been involved.
• Q How does Patient PAL work with Case Management
  or does it replace it?
• A Patient PAL does not replace but rather
  enhances Case Management, where Case Management
  serves as

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LMM Contact Info

• Corporate Headquarters
• Contact Jack G. London, President/CEO
• Phone [phone]
• Fax [phone]
• Address 11920 Southern Highlands Pkwy Suite 103
• Las Vegas, NV 89141
• www.LondonMedicalManagement.com
• www.PatientPAL.org