introduction to 2gb2 and verifyca tm. about the company extensive health care provider background...

Introduction to 2gb2 and verifyCATM

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

verifyCATM 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

verifyCATM 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


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


How does it work? Phase I Approach


Step 1: Audit agreement is executed

between Client and 2gb2

Step 2: Data requirements are

provided to Client by 2gb2

Step 3: De-identified 837 and 835 information is

provided to 2gb2 by Client

Step 4: 2gb2 analyzes the information

provided by running claims over 475K

proprietary algorithms

Step 5: Opportunities are identified

Step 6: 2gb2 prepares and presents report of

findings to Client

How does it work? Phase II Approach


Step 1: Audit agreement is executed

between Client and 2gb2

Step 2: Data requirements are

provided to Provider/Payer or TPA by 2gb2

Step 3: De-identified billing information is provided to 2gb2 by

Provider, Payer or TPA daily

Step 4: 2gb2 analyzes the information provided by running

claims over 475K proprietary algorithms and creating a secure

URL dashboard of workflow containing potential problem

claims for correction in Provider or Payer system.

Step 6: 2gb2 provides access to Client regarding claims flagged for

review by verifyCA, and, where applicable, remitted payment

information

2GB2 has the ability to perform other analytics utilizing the required verifyCATM 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


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

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Proven Results Illustration: School District ASelf-Funded Entity


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

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Proven Results Illustration: Ohio-based Power Management Company – Self Funded Entity


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

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Proven Results Illustration: Utah-based Oil Company – Self-Funded Entity


Contact Us


Kelly Bucci, Principal2gb2

[email protected]

Jennifer Wexler2gb2

[email protected]

mailto:[email protected]

mailto:[email protected]

introduction to 2gb2 and verifyca tm. about the company extensive health care provider background...

Documents

healthcare provider

2gb2 contracts

2gb2 independent audit

audit findings

audited provider

funded employer

verifyca tm slide

company proprietary