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Embed code for: HUB International_PPC_MedProposal_092016
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Medical Claim Review Proposal
HUB International (Consultant)
Claim Review Period: January 1, 2015 through December 31, 2015
Submitted: September 20, 2016
Proposal Guaranteed for 120 Days
Table of Contents
Table of Contents Page 1
A. About PPC Page 2
B. Claim Review Services Program Page 3
Stratified Random Review Page 3
Option I - Focused Review Page 3
Option II - Electronic Edit Review Page 3
Option III – Operational Review Page 3
Scope of Service Page 5
Review Process Page 9
Industry Standards Page 10
Sample Questionnaire Page 11
Claim Review Timeline Page 13
C. Pricing and Reporting Page 14
Fee Page 14
Billing Page 14
Reporting Page 16
D. Staff Support Page 23
Nan L. Coleman, Project Manager Page 23
Diana M. Valdez, Project Manager Page 24
E. References Page 25
F. Summary Page 26
A. About PPC
PPC Partner Plus Consulting, Inc. (PPC) was founded in 1997 in response to a need in the industry for consulting and process review services focused on claims administration. PPC staff has many years of experience in healthcare claims, including healthcare process review and claim management, for insurance carriers, third party administrators and the managed care industry. PPC services include: Healthcare Claim Reviews, Self-Funded and Insured; Pre and Post Implementation Reviews, Outsourced TPA Internal Daily Claim Reviews, including claims and process reviews; SSAE 16 Claim Reviews (Service Claim Reviewers working with partner CPA Firm); Stop Loss and Reinsurance Claim Reviews; Underwriting Claim Reviews; Premium Accounting Claim Reviews; Overpayment Identification and Recovery; Acquisitions and Mergers – Operational Due Diligence; Operational Review – Process and Procedures. PPC is not a benefit consulting company. The primary focus is to perform healthcare Claim Reviews and claim management services for PPC clients.
PPC is DBE (Disadvantaged Business Enterprise) certified and SBE (Small Business Enterprise) certified by NCTRCA (North Central Texas Regional Certification Agency) and is HUB (Historically Underutilized Business) certified by the Texas Comptroller of Public Accounts.
PPC has significant experience in conducting claims administration reviews of insurance carriers, managed care organizations, clinical utilization organizations and third party administrators. PPC has conducted on-site claims administration reviews on most of the major insurance companies and third party administrators. PPC Claim Reviewers are experienced in reviewing all types of plan designs, including Health Savings Account – HSA, EPO, POS, PPO, HDHP, HMO, Indemnity, Limited Benefit Plans, Mental Health, Dental, Vision and Pharmacy. PPC reviewers stay abreast of all Affordable Care Act (ACA) healthcare reform legislative mandates and are experienced in the review of the new legislative mandated health plans.
PPC has an excellent reputation with its clients and is pleased to furnish references in Section E. References.
B. Claim Review Services Program
Stratified Random Review
Using proprietary methods and ACL audit software, PPC will construct a statistically valid stratified random sample. Based on experience with large employers, the ACL audit software typically indicates a random selection of 200 claims. This sample size will provide a confidence level of 95% with precision reliability of 3% assuming the claims error rate is 5% or less.
This is based on PPC receiving the data electronically and in a format that can be converted for a stratified selection. This review will include a review of all claims paid for the review period to include the domestic claims paid at CLAIM ADMINISTRATOR facilities.
Option I – Focused Review
Using proprietary methods and software, PPC will construct a focused sample of the highest dollar claims paid in the claim review period.
Option II– Electronic Edit Review
PPC performs reviews to evaluate health plan vendor claims administration performance in specific payment categories including handling of duplicate claims, payments for excluded services and other areas. The PPC reviews encompass detailed analyses of standardized claims data sets to identify potential overpayments. The electronic analyses are typically accompanied by an on-site sample review to validate findings, propose corrective actions including system or process changes and identify specific claims for overpayment recovery.
Option III – Operational Review
PPC performs reviews to evaluate the operational processes of vendor claim administration. This detailed review includes onsite review of processing location with office workflow to include: Claim procedures, forms and communication process, training programs, exception processing, cost containment procedures, reference manuals, quality of internal audit system, review of staffing, including personnel turnover and claim backlog to evaluate proper staffing levels, utilization management and compliance with HIPAA Privacy and Security regulations.
Scope of Service
PPC suggests a multi-method approach to the claim review services for HUB International, Consultant.
The claim review goal for PPC is to ensure that claims are being processed in accordance with the plan benefits and any overpayments or underpayments identified are correctly adjusted and monies recovered by CLAIM ADMINISTRATOR. The objective is for all parties to work as a team to proactively resolve any potential issues.
PPC will use a data extract from CLAIM ADMINISTRATOR to do a selection of claims for the purpose of developing a random stratified review. A selection for the focused claim review (Option I) and the electronic edit claim review (Option II) will be performed if these reviews are selected by HUB International, Consultant.
Claim Reviews will be performed at the office of CLAIM ADMINISTRATOR for the medical claim review.
Turnaround time will be documented on claims reviewed, to include “paid claims” and “processed claims” as defined by CLAIM ADMINISTRATOR.
Eligibility will be reviewed and PPC will verify on each claim paid that the claimant is included in the plan.
Review to determine claim accuracy payment is in accordance with plan benefits, including verification of medical necessity, plan parameters, coordination of benefits, pre-certification and case management, third party liability and other cost control measures, all aspects of plan compliance, controls and procedures, network discounts, bundling and up-coding practices, medical necessity, and reasonable fees and duplicates.
Verify on each claim paid that the claimant is included in the plan, the services paid for are covered by the plan and the payment amount is correct.
Verify claims were processed in accordance with plan exclusions.
Verify assignments of benefits were processed accurately.
Current overpayment report will be reviewed if PPC is able to obtain the report from CLAIM ADMINISTRATOR.
Hospital network discounts paper contracts will be reviewed if PPC is able to obtain the contracts from CLAIM ADMINISTRATOR. This review will determine if discounts are being loaded correctly and if not loaded to the claim system (and many hospital contracts are not loaded) determine that the processing staff is correctly interpreting and calculating the hospital discounts. Based on prior experience with CLAIM ADMINISTRATOR, they will allow a limited review of hospital network discount paper contracts.
Specific stop loss claims will be reviewed to verify that specific stop loss dollars submitted to the stop loss carrier balance to the data furnished by CLAIM ADMINISTRATOR.
Data extract will be obtained from CLAIM ADMINISTRATOR and PPC will perform an electronic edit review on this data. (Option II) This electronic edit review will be used to identify potential issues. Once the issues are identified through data review, the claims will be submitted to CLAIM ADMINISTRATOR on a selection list and these claims reviewed during the on-site review. For this review, there will be a review of 35 claims. This data extract will be the same as the one used for the stratified random selection.
Plan documents will be reviewed for edits to identify potential overpayments. Edits are based on the plan language and the data fields available to PPC in the data extract.
1) Duplicate claims
2) Pre-certification penalties
Obesity or morbid obesity
Assistant surgery and co-surgery
Pregnancy of dependent daughter
Coordination of benefits
Turnaround time will be reviewed through the electronic data, measuring the total population.
PPC will perform a review of claims incurred and paid after the termination date of coverage for the entire population of claims if HUB International, Consultant will furnish PPC a list of terminated employees during this claim review period.
Data review is dependent on the data availability and the fields available within that data.
From the random stratified claim review, the high dollar focused claim review and the electronic edit claim review, PPC will make several determinations to present to HUB International, Consultant.
PPC will determine the financial accuracy, payment accuracy, procedural accuracy and the eligibility accuracy, based on the stratified random selection.
The following measurements will be presented to HUB International, Consultant, based on the stratified random claim review:
The results will be measured against industry standards.
The results will be measured against contractual performance guarantees.
The turnaround time for claims reviewed will be documented and compared to industry standards and contractual performance guarantees, if any. The turnaround time for the entire population will be documented and compared to industry standards and contractual performance guarantees. (Option II)
All identified errors will be documented in detail with the reason for the error documented.
System control deficiencies for claims processing will be documented based on the claims reviewed. Trends and recommendations for improvement will be documented. The recommendations will include system and plan document issues, as well as benefit interpretation and in some instances, retraining processing staff on specific issues.
PPC will present a detailed claim review report to HUB International, Consultant, outlining the complete claim review process and results of the medical claim review, including the details of each error identified.
The report will contain an executive overview.
Claim turnaround will be documented across the total population (Option II) and also for the random selection and high dollar selection. Claim turnaround will be compared to industry standards and to performance guarantees.
The highest dollar claims will be documented and explained in the report if Option I is selected.
The electronic edit errors will be documented and explained in the report if Option II is selected.
Eligibility accuracy for the claims reviewed will be documented and explained in the report.
All identified errors will be documented in detail.
System control deficiencies for claims processing will be documented based on the claims reviewed.
Recommendations for improvement will be presented to HUB International, Consultant. These recommendations will include system and plan document issues, as well as benefit interpretations and in some instances, retraining processing staff on specific issues.
PPC will provide a detailed analysis of the operational assessment of the claim administration office if Option III for an operational review assessment is selected.
PPC will work through the claim review process with CLAIM ADMINISTRATOR and will keep HUB International, Consultant informed in accordance with communication guidelines established. PPC’s standard process is to advise the client of the status of the claim review as each step is completed. This communication typically occurs through email communication.
CLAIM ADMINISTRATOR will provide the complete claims data in the PPC data file requirements and from that data, claim review selections will be provided to CLAIM ADMINISTRATOR. PPC will accept their standard claim data extract if PPC is able to receive the required fields and our past experience with CLAIM ADMINISTRATOR is that we are able to work with CLAIM ADMINISTRATOR data.
Both HUB International, Consultant and PPC will be required to complete the CLAIM ADMINISTRATOR Non-Disclosure Claim Review Agreement and HUB International, Consultant and PPC must sign the CLAIM ADMINISTRATOR Non-Disclosure Claim Review Agreement. CLAIM ADMINISTRATOR will require the document to be signed by all parties prior to scheduling the on-site review.
The data extract will then be requested from CLAIM ADMINISTRATOR. PPC and CLAIM ADMINISTRATOR will schedule a date for the on-site review. After receiving the data extract, PPC will provide CLAIM ADMINISTRATOR with the selection lists of claims to be reviewed. CLAIM ADMINISTRATOR will make copies of claims and screen prints as requested by PPC. PPC will provide CLAIM ADMINISTRATOR with a detailed Claim Review Scope prior to the on-site review.
Each claim will be reviewed (re-adjudicated) by the PPC staff with findings recorded on PPC’s software. CLAIM ADMINISTRATOR will be given the opportunity to review the errors, commonly referred to as the rebuttal process. PPC and CLAIM ADMINISTRATOR will attempt to resolve every claim issue while on-site. If this is not possible, a specific time for final rebuttals will be confirmed between PPC and CLAIM ADMINISTRATOR. CLAIM ADMINISTRATOR will be expected to back up any rebuttal position with appropriate documentation. This protocol is intended to facilitate the process of building a consensus on the claim review findings.
PPC will document the claim review process by producing a Medical Claim Review Report. This report will document the errors identified, the accuracy of payment, the types of errors and the trends and recommendations for improvement.
A draft report will be sent to CLAIM ADMINISTRATOR and CLAIM ADMINISTRATOR will respond in writing. This response will become part of the Medical Claim Review Report.
A final report will be presented to HUB International, Consultant.
The dollar effect of payment errors expressed as a percentage. This measure is calculated by dividing the total dollars paid correctly by the total dollars paid within the claim review sample. Dollars paid correctly is determined by subtracting the gross dollars paid in error (the absolute value of overpaid dollars plus the absolute value of underpaid dollars) from the total dollars paid.
Minimum standard for “good” performance is 99.0% and “excellent” performance is 99.5%.
Claim Payment Accuracy
The number of benefit payment checks issued for the correct dollar amount divided by the number of checks in the claim review sample. This “frequency” measure reflects the percentage of instances in which a check is either an overpayment or an underpayment.
Minimum standard for “good” performance is 97.0% and “excellent” performance is 98.5%.
Claim Procedural Accuracy
The number of benefit payment claims processed with no errors (payment and nonpayment errors) divided by the number of claims in the claim review sample.
Minimum standard for “good” performance is 95% and “excellent” performance is 97.0%.
The period from the receipt of all the information needed to process a claim until the transaction is entirely completed.
Minimum standard for “good” performance is 80% of all claims paid in 14 calendar days and “excellent” performance are 85% of all claims paid in 14 calendar days.
Minimum standard for “good” performance for high dollar claims is 80% of all claims paid in 30 calendar days and “excellent” performance are 85% of all claims paid in 30 calendar days.
CLAIMS AND OPERATIONAL CLAIM REVIEW QUESTIONNAIRE
HUB INTERNATIONAL, CONSULTANT
QUESTIONNAIRE TABLE OF CONTENTS
Claim System, Security, HIPAA Page
Pre-Certification, Case Management Page
Staffing, Training Page
Claim Procedures, Quality Assessment Page
Non-Network Negotiations Page
Customer Service Page
Coordination of Benefits Page
Stop Loss Reinsurance Page
Questionnaire - Documents Requested:
Copy of the Plan Document, including all amendments, for the incurred dates of the claim review period.
Copy of the Summary Plan Description for the incurred dates of the claim review period.
Copies of plan amendments or changes to administrative procedures not clearly defined in Plan Document or Summary Plan Description.
Copy of the most recent Administrative Services Agreement, including Performance Guarantees, if any.
SAS 70 Report.
Overpayment report showing all overpayments, collected and uncollected overpayments as of the current date.
Specific stop loss deductible amount, coverage dates and the report for claim review period, showing specific stop loss claims exceeding deductible, with detail of submitted and received reimbursements for each claimant.
Coordination of Benefits report for claim review period.
Subrogation, including dollar amounts reimbursed and outstanding reimbursements.
Claim Review Timeline
CLAIM ADMINISTRATOR notified of claim review by HUB
International, Consultant Week 1*
PPC and HUB International, Consultant sign Letter of Agreement Week 2
PPC and HUB International, Consultant sign Claim Review
Agreement Week 3
Schedule on-site claim review Week 4
Request data from CLAIM ADMINISTRATOR Week 4
Send Claim Review Scope to CLAIM ADMINISTRATOR Week 4
Receive data from CLAIM ADMINISTRATOR Week 6*
Complete review of data, stratified random selection,
focused selection, electronic edit selection Week 8
Send selection list to CLAIM ADMINISTRATOR Week 8*
Documentation prepared by CLAIM ADMINISTRATOR Week 10
Claim review medical claims on-site at CLAIM ADMINISTRATOR Week 15*
Claim review response from CLAIM ADMINISTRATOR Week 16*
Preparation of report Week 18
Draft report to CLAIM ADMINISTRATOR Week 18*
Response to report from CLAIM ADMINISTRATOR Week 20
Presentation of report to HUB International, Consultant Week 20*
This timeline is based on PPC’s experience in working with Insurance Carriers and Third Party Administrators. PPC will begin the process immediately upon the awarding of the project and the signing of the Letter of Agreement.
C. Pricing and Reporting
Stratified Random Claim Review
Stratified Random Claim Review
200 claims $ 15,000
Focused Claim Review
15 highest dollar claims $ 2,250
Electronic Edit Claim Review
Detailed analyses of claims data for electronic $6,500
review of claims
Claim Review of electronic claims $ 2,450
Maximum 35 claims
Operational Review $ 6,500
Total Stratified Random, Option I, Option II, Option III $ 32,700
Options I, II and III are supplemental claim reviews to the Random Claim Review and HUB International, Consultant may elect any or all of these options.
PPC recommends HUB International, Consultant select all services because this expanded scope gives HUB International, Consultant the most comprehensive claim review service review.
PPC requests payment of one-half of the fee in advance of the review.
Travel expenses are not included in the service fee. Reasonable travel expenses will be reimbursed by HUB International, Consultant following the on-site review. Travel expenses are estimated at $6,500.
The final one-half of the fee will be presented following the completion of the final report.
Service fees are due within 15 days of presentation of the invoice. A late charge will be applied to any payment not received within thirty days following presentation of the invoice.
PPC will present a Comprehensive Claim Review Report to HUB International, Consultant when the on-site is complete.
Example of the Medical Claim Review Report
Representative reports, charts and graphs
The following charts illustrate comparisons of performance to industry standards:
Stratified Random Claim Review
Financial, Payment and Procedural Accuracy
(Date) to (Date)
Claims Paid (Date) through (Date)
Claim Turnaround Time
Comparison to Industry Standards
Claim Turnaround Stratified Random Review (Processed 14 Calendar Days)
Total Claims Paid during the Claim Review Period
Total Claims Paid in the Claim Review Selection
Total Claims Reviewed
Total Financial Dollar Errors
Financial Dollars – Overpayments
Financial Dollars- Underpayments
Network Claims in the Random Claim Review Selection
Number Claims Reviewed
Number Claims with Network Discount
Representative reports, charts and graphs
Electronic Edit Review
Certain edits are developed for an electronic claim review based on coverage and exclusions specific to client. The claims are identified through an electronic edit review, and then on-site the claims are reviewed to determine if an error actually exists. The following are samples of those edits.
Possible Duplicates – Check for duplicate claims within the claim review dates.
Pre-certification Penalties – Determine if pre-certification verification was done, based on the plan benefits, and if penalty should apply on certain claims.
Abortions – Determine if abortion is excluded under the benefit plan and if excluded, determines if any abortion claims were paid.
Acupuncture – Determine if acupuncture is excluded under the benefit plan and if excluded, determine if any acupuncture claims were paid.
Breast Reconstruction – Determine if breast reconstruction is excluded under the benefit plan and if excluded, determine if any breast reconstruction claims were paid.
Cosmetic Surgery - Identify any cosmetic surgeries or procedures that are paid under the benefit plan.
Weight Reduction – Determine if weight reduction is excluded under the benefit plan and if excluded, determine if any weight reduction claims were paid.
Obesity – Determine if obesity is excluded under the benefit plan and if excluded, determines if any obesity claims were paid.
Telephone Consultations – Determine if any telephone consultation claims are paid under the benefit plan.
Dental Care – Determine if dental care, as excluded under the benefit plan, claims are paid and determine if the claims should be excluded.
Infertility – Determine if infertility is excluded under the benefit plan and if excluded, determines if any infertility claims were paid.
Foot Care – Determine if foot care is excluded under the benefit plan and if excluded, determine if foot care claims were paid.
Multiple Surgeries – Determine if multiple surgeries occurred on claims and if so, determine if multiple surgeries were paid correctly. Multiple surgeries are usually addressed in the benefit plan, outlining if second claims are paid at 50%, others 25%, etc. Or if not addressed in the benefit plan, then apply Medicare guidelines to determine if multiple surgeries are paid correctly.
Assistant Surgeon and Co-Surgeon – Determine if assistant surgeon or co-surgeon claims were paid correctly, if surgeon is in the network and assistant surgeon and co-surgeon are not in the network.
Pregnant daughters – Determine if treatment for pregnant daughters is excluded under the benefit plan and if excluded, determine if pregnancy claims were submitted and paid on pregnant daughters.
TMJ – Determine if TMJ treatment is excluded under the benefit plan and if excluded, determine if any TMJ claims were paid.
Coordination of Benefits (COB) - Review the total population of claims to identify all claims on one employee/dependents with any claim payment including coordination of benefits. PPC identifies all claims with COB payment and all claims without COB payment on the employee/dependent and all claims are reviewed to determine overpayment amounts.
Coordination of Benefits (Benefit interpretation). Review COB claims to determine how benefit plan is being interpreted. Review some COB claims and Medicare COB claims to determine proper interpretation of benefit plan.
Overage Dependents – Review some dependents that are in the age range for student dependents and review records to determine if student status has been investigated in a timely manner and if not, are any claims paid on this student dependent. Also, review any dependents that are over the age for student and still covered under the benefit plan. Eligibility for this dependent would need to be determined.
Disabled Dependents – If any disabled dependents are identified, determine if disability has been recently investigated.
Claims Incurred and Paid after Termination – Obtain termination dates from Client and compare the termination dates to the eligibility record by the Claim Administrator. Identify claims incurred and paid after the termination date of the Client and after checking eligibility record, identify any potential overpayments.
Negotiated Discounts – Review claims over $5,000 that have no discount shown in claim record, network, reasonable and customary and negotiated discount. If no discount is shown on claim, claim will be reviewed to determine if discount negotiation was attempted and if not, review the reason.
D. Staff Support
PPC associates are primarily healthcare reviewers. The total staff consists of ten associates, which includes ten consultants. PPC is located in Granbury, Texas. PPC staff all has previous experience in the healthcare industry in claims administration. PPC does not utilize trainees as claims experience is a tool necessary for medical claims reviews.
For staff training, on a national level, PPC staff attends the Self Insurance Institute of America, National Association of Health Underwriters and the Health Insurance Association of America. On a local level, PPC staff attends and participates in the DFW Healthcare Alliance, Texas Association of Benefit Administration, Worldwide Employee Benefits Network and DFW Business Group on Health. Ms. Coleman attended The Institute of Internal Auditors, Effective Auditing of Health Benefits Administration. PPC subscribes to various industry publications.
Nan L. Coleman or Diana M. Valdez, both principals of PPC, manages all claim review projects. Bios below list the experience of both Ms. Coleman and Ms. Valdez.
Bio: Nan L. Coleman
Nan Coleman founded PPC Partner Plus Consulting, Inc. in 1996. As PPC’s President, Nan utilizes her 35 years of experience in management of third party administrators.
Prior to founding PPC Partner-Plus Consulting, Inc., Nan served as Vice President of Field Operations for Centra Benefits Healthcare Administrative Services (TPA), Vice President of Operations for Equifax Healthcare Services (TPA), Senior Vice President of Claims & Group Administration for Health Economics Corporation (TPA) and Group Vice President of Claims for Life Insurance Company of the Southwest (Insurance Carrier). Her executive roles required her to manage staffs of 250 –350 people in various field offices in the USA. Her management areas included managed claims processing, customer service, member services, underwriting, provider relations, account management, reinsurance, flexible spending accounts, Cobra administration, quality audit, contract negotiations, and document management for self-funded medical & dental products, HMO managed care self-funded products, interactive voice response and repricing of claims for PPO.
Nan’s dedication and the power of commitment to client projects is the basis for her success in the health care administration industry. Nan received her Bachelor of Arts in Management from Dallas Baptist University, Dallas, Texas. She is an Affiliate of Life & Health Claims.
Bio: Diana M. Valdez
Diana M. Valdez joined PPC in July 2003 as an Executive Consultant. Diana utilizes her 24 years of healthcare industry experience, including 19 years focused on management of self-funded plans, providing PPC’s clients comprehensive claim reviews of their healthcare benefit programs.
Diana was Senior Vice President of Operations at American Administrative Group (TPA), Senior Vice President/COO for UICI Administrators (TPA), Assistant Vice President of Managed Care Services for Centra Benefits Healthcare Administrative Services (TPA) and Vice President of Client Administration for Third Party Claims Management, a subsidiary of Aetna (TPA). As an executive she has managed over 250 employees with company revenues in excess of $20 million dollars. Her management experience has been in the areas of sales, marketing, account management, audit/training, technical plan support, provider network development, and stop loss administration.
Diana’s past experience with large employer groups, including large governmental entities, provide a breadth of knowledge to the operational claim review and have been instrumental in her success in the healthcare administration arena.
Consultant: Darenda Smith - Gallagher Benefits Services
(Statistical Random, High Dollar and Electronic Claim Review)
Dallas, Texas (972/663-6121)
June Leyendecker, Consultant – McGriff, Seibels & Williams of Texas, Inc.
(Statistical Random, High Dollar, Electronic Edit Claim Reviews, Plan Implementation Review)
San Antonio, TX (210/541-0062)
Consultant: Gene Hart - Lockton Benefits
(Statistical Random, High Dollar and Electronic Edit Claim Review)
Dallas, Texas (214/969-6167)
Consultant: Paula Scott - McQueary Henry Bowles Troy, LLP
Fort Worth, TX (972/340-2319)
Elbit Systems of America
Consultant: David Hinckley, Lockton Benefits (214 969-6113)
(Statistical Random, High Dollar, Electronic Edit, Pharmacy Claim, Plan Implementation Reviews)
City of Wichita Falls
Consultant: Brent Weegar – IPS Advisors, Inc.
(Statistical Random, High Dollar, Electronic Edit Claim Review)
Dallas, TX (214/443-2492)
(Statistical Random, High Dollar, Dental, Electronic Edit and Pharmacy Claim Review) - Minneapolis, MN (612/397-4051)
The random claim review is statistically valid and will develop the statistical validity of the processing and identify the financial accuracy, payment accuracy and procedural accuracy, as well as the timeliness of processing. The random claim review compares outcomes to industry standards and performance guarantees. This claim review allows the client to gain insights into the error patterns in the entire claim population.
The review of high dollar claims confirms that major dollars are being paid correctly. By targeting this claim population, PPC can determine whether the additional reviews conducted by CLAIM ADMINISTRATOR result in better claim practices than are provided to the general claim population. To avoid entering bias into the sampling methodology, the results of these reviews are provided separately.
The focus of the electronic edit claim review is to target the total claim population of claims, identifying system issues, discrepancies in the Summary Plan Descriptions and types of overpayments that might not be identified in the stratified random and high dollar reviews.
The operational review validates the claim procedures and processes for the claim administration office location processing the HUB International, Consultant plan benefits is following all company policies and guidelines, has trained staffing levels, internal quality tracking and is current and applying all healthcare legislative mandates.
PPC Partner-Plus Consulting, Inc. appreciates the opportunity to submit this proposal to HUB International, Consultant.
Medical Claim Review Proposal HUB International, Consultant
12003 as an Executive Consultant. Diana utilizes her 24 years of healthcare industry experience, including 19 years focused on management of self-funded plans, providing PPC’s clients comprehensive claim reviews of their healthcare benefit programs.
The operational review validates the claim procedures and processes for the claim