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ClaimsWatch

Cost-Conscious Strategy
Our claims cost control strategy is designed to maximize our ability to adjudicate claims accurately, fairly and in line with industry "best practices" and SAS 70 control standards.

There are nine components worth noting:

	We have invested $11 million in technology in the last three years, including the Facets claims system from TriZetto. We believe we are the only TPA nationally that has made this level of investment and are already seeing the benefits of automating operations and applying secondary edits that cannot be delivered through any other system. For example, most systems are able to edit on a particular type of service or on a patient but cannot blend the two edits. We are able to establish parameters for the handling of claims tied to any combination of the diagnosis, procedure, place of service, provider, patient or dollar amount.

	All claims processed are subject to fully-integrated clinical edits designed to identify provider billing issues such as the unbundling of charges or upcoding.

	Our offices are staffed with on-site clinicians, so any pre-service request for verification of coverage or questionable procedure is reviewed by a clinician. We supplement the clinicians with access to a number of independent Medical Review Organizations.

	All claims received from non-contracted providers are sent to a vendor where PPO contracts or direct negotiation are used to obtain discounts. For calendar year 2004, we obtained an average discount of 23.4% on 91.2% of claims handled by the vendor.

	We maintain a company-wide focus on healthcare fraud including a Special Investigation Unit (SIU) with representatives in each location. These individuals review all questionable claims, utilize national fraud databases and train staff on identifying fraud.

	We are linked electronically to a Medicare clearinghouse; so all claims with questionable primary versus secondary payment responsibility are checked against Medicare payments. This has been especially valuable since HIPAA privacy took effect, with most Medicare intermediaries refusing to provide coverage or payment information.

	We utilize an Attorney-based Subrogation process to ensure that we protect the assets of the Plan to the best of our abilities. This is different from TPAs that expect their Processors or a designated Senior Processor to pursue recovery or use a vendor that cherry picks cases where they can get a quick contingent payment.

	We are one of the only TPAs in the country that has contracted for continual, random claim audits through a third-party audit firm. We did this because we believe an independent opinion of our results is more credible than that of an individual auditing their former peers and in most cases still interacting socially. The firm is Mulally Insurance Services of Orlando, Florida and they audit a random 3% of all claims processed as well as all claims exceeding $20,000 prior to payment. Our Senior Management Team receives monthly reports of audit results.

	The final component is what we affectionately refer to as the "watchdog". Each night we send a files of all claims paid during the day to a vendor that supplies "retrospective claim surveillance" software to complete a final review of claims. Any claim where they feel a second review by CenBen USA is necessary are submitted on a Review Report received by the time our offices open in the morning. We have designated a team of individuals to review those claims and to either uphold or override the vendor opinion.

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