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ASI Aurora Soft Inc. Operations Nanjing Operations.

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Presentation on theme: "ASI Aurora Soft Inc. Operations Nanjing Operations."— Presentation transcript:

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2 ASI Aurora Soft Inc. Operations Nanjing Operations

3 ASI Aurora Soft Inc. CONFIDENTIAL China Organization Structure Executive Office Compliance Process Team 1Outsourcing Unit Team 4 Team 2 Team 1 Team 3 Group Administration Claims Processing Support Audit/ Quality HR & Admin. Corp. Service IT Dept. Process Team 2 Group Administration Claims Processing Support

4 ASI Aurora Soft Inc. CONFIDENTIAL Life of a Claim US China US China Check/EOB Printing Mail Room O CR Ve ndor Su pport U nit Cl aims D ept. OCR Mail Room Su pport U nit Cl aims D ept. Su pport U nit NON-OCR

5 ASI Aurora Soft Inc. CONFIDENTIAL Member Identification Duplicate Check Reprice Verfication Provider Identification Support Unit: Functions & Flow External Repricing Batch/Claim Reconciliation: 1. Mail Room – OCR Vendor 3. Panther - WLT 2. OCR Vendor – Panther 4. WLT - Website Sort Mail Member Search Preprocessing Data Entry Correspondence Processing Filing Claims Dept.Vendors Houston ChinaUS Support Unit Repricing: internal & external (requires tracking) Mail OCR Fix Errors (Panther) Preprocessing (WLT) Adjudication  ‚  „

6 ASI Aurora Soft Inc. CONFIDENTIAL CPT (Procedure Code) Plan Exclusion? RX order? Coverage Code EOB/Check generated Cost Containment Non-P Negotiation HBA UM Pre-cert Yes Claims Unit: Adjudication Flowchart ICD-9 (Diagnosis Code) Pre-x; Accident; Plan exclusion? Yes Active? OI, FTS No Deny/ Inquiry further De-Dup Dup Not Dup Clarification, itemized bill need to be obtained Patient Eligible?

7 ASI Aurora Soft Inc. CONFIDENTIAL Claims Unit: Correspondence/Call tracker/E-mail  Additional info received OI, FTS, Injury Details, etc.  Payment Dispute  Either from Provider or member  Check Status Tracer  Claims Status look-up  Eligibility  Benefits inquiries  Identify Problems  Further Research  Confirm Re-pricing  Update processing system  Process/ re-process  Re-issue checks  Referred to other desk  Form type of reply

8 ASI Aurora Soft Inc. CONFIDENTIAL Group Administration: Functions

9 ASI Aurora Soft Inc. CONFIDENTIAL GA: Member Maintenance & Administration Web New Enrollment Eligibility Change Online Finalization Termination Online Finalization COBRA Participant Upon receipt of COBRA Premium, update eligibility Record in WLT. COBRA Election Notice Member Move ID Card Process Special Card Request WLT Online Finalization Change in WLT Access Program Initial COBRA Notice Welcome Letter Including Web Login ID Card New Enrollment Package Automatically Process Card Program

10 ASI Aurora Soft Inc. CONFIDENTIAL Reporting System & Administration WebWLT Stop Loss Reporting & Filing Claim Analysis Report Client Customized Report Premium Billing PPO, UM Vendors, S/L Carrier & Broker etc. Remit premium or commission. Upon receipt of premium payment, update WLT.

11 ASI Aurora Soft Inc. CONFIDENTIAL We constantly strive to find innovative methods for re- engineering the claims administration process to improve the effectiveness and scalability of our operations. These changes we have made in breaking down the claims process enable us to:  Have better performance measures and control  Operate with a higher degree of specialization  Decrease training time  Reduce reliance on any one individual  Enables us to move closer to a variable unit cost production structure (contractor) Process Re-Engineering

12 ASI Aurora Soft Inc. CONFIDENTIAL Maximizing productivity is one of our top operational priorities. This goal is emphasized during all process design discussions and is evident in our efforts to continuously measure, manage, and improve the productivity, efficiency, and effectiveness of our various teams. Focus on Productivity & Quality To ensure our quality standards consistently meet and exceed our quality goals, we have implemented a number of internal quality assurance procedures. Random audits and cross-checking Meetings with client service teams Supervisory & management reviews Monthly seminars on “Errors & Risks” and regular training

13 ASI Aurora Soft Inc. CONFIDENTIAL Our management, operational, and client reporting enables our business and client service teams to enhance customer satisfaction.  Daily reports: production, productivity, & status  QC reports  Bi-monthly reports: paid claims; inventory; claims exceeding $5,000; cases with pre-certification; cases in large case management  Aggregate reports (claim $ amount by group) These various reports offer important analytical insight which allows us to: 1) measure & optimize our operations and 2) take proactive steps to increase client satisfaction. Management Control

14 ASI Aurora Soft Inc. CONFIDENTIAL HIPAA & Regulatory Issues Privacy & Security  System security: users are assigned system logins & passwords with appropriate security levels  Physical security: security codes changed regularly and visitors not allowed in processing areas  Documents containing PHI are kept within the operations department  Claims and correspondence containing PHI are shredded prior to disposal Health Insurance Portability  We request Creditable Coverage Certificate for every eligible participant EDI  We are able to receive claims via EDI

15 ASI Aurora Soft Inc. CONFIDENTIAL Recruitment and Training GENERAL We recognize that our employees are our most important asset. Hence, we screen new applicants carefully, conducting multiple rounds of in-depth interviews and reference checks. We review each employee’s performance regularly and build leadership from within. Our “pay for performance” compensation structure and benefit packages are competitive and will enable us to retain our valuable members.

16 ASI Aurora Soft Inc. CONFIDENTIAL We hire people who:  Have good command of English  Have solid work ethic  Work well in a team environment and can work with a diverse group of people  Exhibit a track record of striving for excellence  Understand the importance of responsibility and ownership of work  Have initiative and leadership potential For recruiting, we :  Review résumés, educational background, accomplishments, and work experience  Conduct multiple rounds of in-person interviews  Give candidates an English comprehension & typing test Hiring Strategy

17 ASI Aurora Soft Inc. CONFIDENTIAL In determining salaries we:  Examine each situation on an individual basis  Adhere to a performance grading system and tie pay to performance  Strive to create benchmarks which are perceived as fair and consistent for comparable positions throughout the firm  Offer competitive compensation packages relative to the market in our area Our benefits packages include:  Pension Benefits  Medical, Unemployment, and Worker’s Compensation Insurance  Discretionary Bonus  Paid Holidays & Vacations Salaries and Benefits

18 ASI Aurora Soft Inc. CONFIDENTIAL Training The HR Department is responsible for training and development of training materials; however, all team members play a role in the training process. There are two primary phases for the Claims Examiner training: A.Foundational Training Sessions B. Claim Adjudication Exercise Sessions

19 ASI Aurora Soft Inc. CONFIDENTIAL Training A. Foundational Training Sessions:  3 days “Overview of Health Insurance”: terms, definitions, codes… followed by a comprehension test.  2 days “Identification of Claims Forms”: HCFA–1500, UB92, Dental Claim Form, EOB.  2 days “Plan Overview”: deductible, limits, benefits, covered charges, and exclusions.  7 days “Systems Training”, “8 Steps of Claim Adjudication”…. followed by a comprehension test.

20 ASI Aurora Soft Inc. CONFIDENTIAL Eight Steps of Claim Adjudication: 1) Claim form 2) Plan 3) Eligibility 4) Dates 5)Charges 6) Deductible 7) Coinsurance 8) Benefits B. Claim adjudication exercise sessions: The duration of the exercise phase lasts approximately 3 to 5 weeks, depending on the trainee’s comprehension of claim procedures. During this phase, the trainer will do the following: Training

21 ASI Aurora Soft Inc. CONFIDENTIAL Select less complicated or low dollar amount claims for trainees to adjudicate. Most often, these types of claims would be dental claims, pharmacy bills, or claims under $100.  Constant monitoring of progress  Quality control (100% audit)  Group discussion on common problems & important considerations  Ongoing performance reviews After the exercise phase is successfully concluded, the trainee will be assigned junior examiner functions by their team leader. Training

22 ASI Aurora Soft Inc. CONFIDENTIAL We have developed and implemented a continuous cross-training system where all team members serve as both trainers and trainees. We employ this system in our effort to:  Provide an opportunity for professional growth to all our employees consistent with our message of rewarding value and building moral  Foster sharing of information and encourage continual development to free up time for increasingly more value-add responsibilities  Establish a natural filter system to identify leadership  Create a scalable training platform to support expansion Employees are rewarded for successfully managing the delegation of responsibilities and for raising the levels of their peers. Continuous Cross Training System

23 ASI Aurora Soft Inc. CONFIDENTIAL Foundational Training Materials:  Claim Adjudication Overview  Medical Processor Training Aids Advanced Training Materials:  Claims Administration Handbook Training Materials

24 ASI Aurora Soft Inc. CONFIDENTIAL Training Schedule

25 ASI Aurora Soft Inc. CONFIDENTIAL Acquisition and Transition To ensure a successful acquisition transition, we have a systematic procedure for planning and implementing the transition process. Analysis  Volumes based on historical volumes  Complexity of SPDs  Plan set-up integrity and questions  System analysis  Current operational structure  Identify areas for improvement Planning  Staffing plan (reduction phases and resources needed)  Operational planning to establish timeline and task list  IT/ Systems planning

26 ASI Aurora Soft Inc. CONFIDENTIAL Acquisition and Transition Implementation  Execute on operational transition plan  Improve processes as we centralize operations

27 ASI Aurora Soft Inc. CONFIDENTIAL Implementation Items  Transfer of important records and information  Send out initial COBRA notices & new ID cards  Carry out client communication plan and establish weekly client conference calls  Notify appropriate third-party vendors (i.e. PPO, UR, PBM, MGU, and clearinghouse vendors)  Execute Business Associate Agreement with outside vendors  Request data file format from vendors  Request Certificate of Creditable Coverage from clients Acquisition and Implementation

28 ASI Aurora Soft Inc. CONFIDENTIAL Claims System Experience  GBAS  LuminX  HSP  RIMS  WLT  CAPS/2020  Eldorado  ClaimFacts  Genelco  Facets

29 ASI Aurora Soft Inc. CONFIDENTIAL Expansion Modules Executive Office Compliance Process Team 1Outsourcing Unit Audit/ QualityHR & Admin. Corp. Service IT Dept. Process Team 2 Director Operations Process Team 3


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