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Published byStanley Oakey
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Introduction to 2gb2 and verifyCA TM
About the Company Extensive health care provider background Sister company to ERIS Medical Technologies (www.erismed.com) Years of consulting experience with focus on provider: ‒Revenue cycle ‒Pricing ‒Charge capture and related services ‒Compliance and correct coding Leading the health care industry in cutting-edge software product development Executive Team ‒Kelly Bucci ‒Jennifer Wexler www.2gb2audit.com 2GB2: About the Company Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 2
verifyCA TM Solution: ‒Fully-automated, claims “payment integrity” solution ‒Allows self-funded entities to independently audit the payment integrity of 100% of the healthcare claims paid on their behalf by Third Party Administrators (TPAs) ‒Employs over 475,000 proprietary, national and payer-specific billing compliance algorithms to identify improperly billed and paid healthcare claims (duplicate charges, mismatched services, unbundled services and supplies, other billing compliance issues) ‒Operates on standard, readily-available claims and payment transaction data delivered in common file formats ‒.NET web-based cloud environment ‒HITECH Act compliant ‒Functionality supports historical/retrospective assessment and ongoing, prospective payment integrity auditing/monitoring verifyCA TM Client: –Any healthcare provider that is going through a government or third-party payer audit –Any public or private employer that self-funds its employee healthcare benefits The Product Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 3
Self-funded Employer: 2gb2 contracts with self-funded employer to provide independent “retrospective” audit of patient bills by collecting 12- 36 months worth of claims submissions (de-identified 837) and remit information (de-identified 835) from the employer’s claims administrator (Insurer or TPA). Patient bills are processed through date-driven system algorithms or “edits” to identify potential overpayments by comparing provider submitted bills to remit information and noting where inappropriate charges were submitted by the provider and ultimately paid by the third-party payer. Audited Provider: 2gb2 contracts with the provider to deliver an independent audit of targeted paid bill data and associated remittance information commensurate to the government or third-party payer audit time period. 2gb2 independent audit results will then be compared with the findings of the payer audit, noting any discrepancies between the two audit findings. Should any discrepancies exist, 2gb2 will provide appropriate clinical or billing regulation references to justify the findings. 2gb2 will also perform a missing charge assessment for received paid bill data that is within timely filing requirements, to potentially offset any due pay-back by the audited provider. Phase I: Assessment and Quantification of Potential Overpayments Our Comprehensive Two-Phase Approach Proprietary and Confidential., Copyright © 2014 2gb2, LLC. All Rights Reserved. 4
Self-funded Employer: Pre-screens every bill from hospitals, physicians, and related medical service providers for excess cost as part of the bill submission process to the insurer or third party administrator. Promotes a more active role by the employer to participate with their selected claims administrator (insurer) or third party administrator through real-time on-line monitoring metrics. Verifies that the employer is controlling health care costs prior to payment – rather than focusing solely on reducing benefits or increasing cost sharing to maintain an affordable benefit package. Audited Provider: Pre-screens all patient charges for both missing as well as uncompliant charges, prior to bill submission, for all payers. Provides an automated methodology by which the provider can correct these patient charges before bill submission to the third-party payer, allowing for a clean and comprehensive initial patient bill. Phase II: Prospective “Daily” Audit of Claims and Monitoring Metrics Our Comprehensive Two-Phase Approach Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 4
How does it work? Phase I Approach Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 5
How does it work? Phase II Approach Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 6
2GB2 has the ability to perform other analytics utilizing the required verifyCA TM data elements. Examples of these include but are not limited to: ‒Provider payment tracking and trending ‒Provider charge-error trending ‒Payer overpayment-error trending ‒Customized reporting to individual client needs Additional Services Other Services offered by 2GB2 Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 4
Client Results and Other Measurable Data Analytics
Employer: School District “A” ‒1,244 covered employees ‒Fully insured ‒January 1 to December 31 plan year ‒2010 incurred medical claims = $13M ‒2011 premium = $16M Results: Over $1M in Annual Overpayments ‒6% of all employer patient bills had one or more overpayments associated with it ‒While all claim types were evaluated, 21% of all hospital outpatient claims had one or more overpayments ‒2GB2 did not receive the full set of claims data for the specified time period, thus diminishing the true value of reported overpayments 10 Proven Results Illustration: School District A Self-Funded Entity Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 8
Employer: Power Management Company “A” ‒101,000 covered employees ‒Self-Funded entity ‒Audit comprised of Workers Compensation claims from January 2013 – December 2013 ‒A total of 6,823 Workers Compensation claims were audited for this time period Results: Approximately $350K in Annual Overpayments ‒This entity paid $2.3M in workers compensation claims over this 1- year time period ‒These overpayments equated to almost 15% of total expenditure for workers compensation health care claims ‒2GB2 is currently in the process of assisting employer and associated TPA recover overpayments identified in the audit 11 Proven Results Illustration: Ohio-based Power Management Company – Self Funded Entity Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 9
Employer: Oil Company “A” ‒5,800 covered employees ‒Self-funded and self-administered ‒Audit comprised of all employee medical claims from June 2012 – June 2013 Results: Approximately $850K in Annual Overpayments – 20% of all employer patient bills had one or more overpayments associated with it – These overpayments equated to 3% of total expenditure for employee health care claims – 2GB2 was unable to collect all data elements in the sample (example: no diagnosis codes were provided), therefore not all edits could be run. By running these additional edits, it is expected that another 1% in net overpayment findings could be identified 12 Proven Results Illustration: Utah-based Oil Company – Self-Funded Entity Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 9
Contact Us Proprietary and Confidential. Copyright © 2014 2gb2, LLC. All Rights Reserved. 4 Kelly Bucci, Principal 2gb2 firstname.lastname@example.org Jennifer Wexler 2gb2 email@example.com
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