Service – Creating Best Practice Services

Integrity and a long history of creating, developing, and managing the medical cost containment programs we provide to our clients, inclusive of demonstrated results, our history and corporate mission is to deliver unparalleled services to our clients that distinguish ICS in the market and promotes a statement of qualification and experience that is not easy to match or replicate.  Shown below are our Core Compentencies.

The success of our operations and programs implementation is due in large part to two guiding principles; consistency and discipline. We work with our customers to develop protocols, procedures and workflows that guide the majority of activities associated with a project and/or program. Having these guidelines in place provides the platform from which consistency in approach and discipline is established in what we feel are the three critical components of any successful service delivery, People, Process, and Technology.

An example of this how we practice consistency and discipline in managing our services is through our Implementation process. We feel strongly that Implementation is the key to a program’s success.

Clear, frequent, documented communication is the key ingredient to a successful implementation.  If good communication exists, an implementation will go smoothly. We feel a strong and concise Implementation Plan will have the downstream impact of setting the process to manage the compliance of program efficacy

ICS has the experience implementing a wide array of programs, ranging from thoe referral based programs to a completely integrated and comprehensive medical cost containment service program, and understands the many issues surrounding what may appear to be the simplest decision. We can anticipate your needs, bring a wealth of ideas and alternative solutions to facilitate and insure a smooth and successful implementation.

We feel any service readiness plan that creates effective communication protocols and procedures has to start with a structured and well-defined Implementation Plan.  We take great pride in working closely with our clients in the development of comprehensive transition and implementation plans that have repeatedly proven successful.

Implementation & Account Management Foundation

IMPLEMENTATION

• Implementation is the Key to Program success
• Kick-off assessment to set project expectations by dedicated Team
• Detailed knowledge gathering round table meetings to critical path deliverables
• Review current workflow, confirm business and technical requirements

ACCOUNT MANAGEMENT

• Senior Level Account Management
• Customized service programs and reporting
• Ad Hoc Status Calls
• Monthly Program Updates
• Quarterly Stewardship Meetings and Efficacy Outcomes

We believe that today’s leading technology solution may become obsolete in the future.  This fact drives us to always be attuned to our client and market’s latest challenges, looking for the best solutions and the technology needed to make them work.  We believe that our future is dependent on being visionary and finding the solutions to our client’s problems that may not yet exist or be recognized

Technology – Mitchell SmartAdvisor

ICS utilizes the industry leading medical bill review software, SmartAdvisor for the Fee Schedule and Usual and Customary Review (UCR) process.  In addition, SmartAdvisor is used to support our extensive and robust PPO ICING services as well as our Out of Network Negotiation IRON workflow.

This system utilizes these highly flexible technologies as the basis for an extremely powerful and robust pricing engine, carefully balancing the efficiency of automated pricing functions with the opportunity for intervention, control, and customization as required to meet the diverse needs of the industry.

SmartAdvisor provides a review of all medical bills including inpatient, outpatient, diagnostic testing, prescription medicine, skilled nursing, home health.   Fee schedules are utilized in all states where required.   ICS also uses DRG grouping software and surgical coding edits.   In non-fee schedule states, ICS utilizes Fair Health for usual and customary pricing.

The reimbursement process for medical bills is made complex by the many considerations that are part of determining the appropriate reimbursement rate for medical services.  These considerations include:

• State mandated fee schedules
• Relatedness of treatment or testing to the injury sustained
• Appropriateness of treatment or testing for the underlying injury
• Determination as to whether the treatment has been approved within the medical management process
• Proper coding of the bill

In addition to the proper application of fee schedule reimbursement rates, the SmartAdvisor workflow and process supports the review of certain bills by medical coding experts and by nurse specialists.  This Code Review process systematically identifies improperly up-coded bills, unbundled procedures, and employs other clinical considerations that result in significant savings beyond fee schedule savings

SmartAdvisor has many system edits that we leverage on a customized basis for our clients ensuring the edits meet specific client needs or jurisidicational requirements. Some system edits include:

• Billing anomalies against State Fee Schedule
• Inappropriate Billing and Coding identiciation against National Correct Coding Initiative Data Tables
• Inapprorpriate Billing and Coding idenification against AMA Medical Edit Guidelines
• Sytem driven bundling/unbundling of codes and services
• Rarity Edit Rulebase – through selection of tolerance levels to determine bills that contain codes that are rarely seen.
• Medical Alert Module – Medical Alert advises the end user during bill entry when a claim has exceeded its predetermined limits (UR parameters). Additionally, other fields set up on the client record define the information that displays on the Medical Alert window, including Days since Date of Injury/Loss, Maximum Allowance, Maximum Number of Visits, and Warning Number of Visits
• Integrated Utilization Review module that recognize billed treatment that is outside of the treatment plan for a specific claim. These bills may be automatically reduced or pended to a user for review.

Shown below is a schematic that shows how a medical bill flows through the SmartAdvisor application, leveraging the Bill Review Engine, the Capstone Decision Manager, the PPO EDI Bridge, Provider Check Payment, State Reporting, and the Claims System Payment data integration

Technology – Mitchell – Claims Examiner Portal

The Claims Examiner Portal(CEP) is a powerful, secure web-based solution for utilization alerts, bill authorization, EOR reprints, bill management, and provider relations. This portal provides a basic web version of the SmartAdvisor application that can be used by examiners, physicians, and other external entities.

CEP gives users an online “window” into the bill-review process. The two main functions of CEP include:

• History inquiries: Real-time information exchange with the SmartAdvisor application.
• Examiner approval: Allows examiners to approve and deny bills and to modify editable fields and charges.

Through this web-based tool, users can get instant information regarding bills that have been submitted for review. In addition, users have access to extensive current and historical information (at the header and detail level) generated by the bill review process including EORs, sendbacks, and reconsiderations

Technology – ReviewStat Case Management Software

ReviewStat has been developed with case management experts determining the data, workflow and reports that are essential to the case management process.  Its users continually enhance the system, with essential input from case managers, claims adjusters, risk managers and consultants.  ReviewStat supports our First Report of Injury Call Ceter, Early Intervention Nurse Case Management, Return to Work and Disability Management, Prospective Utilization Review/Pre Certification, and MSP Compliance services.

ReviewStat is a robust case management infrastructure optimized for the proactive case manager that creates bottom line results in today’s competitive case management environment. The need for results and information from clients have placed a premium on an application that can deliver on these market demands.  ReviewStat’s technical architecture provides flexible implementation options for maximum productivity and low maintenance.

Some system features include:

• State-of-the-Art Internet Based Information System
• Comprehensive Medical Management Platform
• User-Friendly Connection and Navigation
• User-Directed task Reminders and Scheduling
• Real-Time Information and Report Access
• Secure Internal Communication System
• Comprehensive Data Collection and Tracking
• Injury and Milestone Event Management & Email Notification
• Environmentally Friendly Paperless System
• Standard import and export utilities allowing for an easy interface with external systems
• Comprehensive reporting through our suite of standard reports and the ability to create or customize reports to meet our client’s individual needs
• Integrated with SmartAdvisor/CEP

The ICS Nurse Case Manager, Injury Care Coordinator, and MSP Compliance Manager will utilize Review Stat as their application to manage all claims referred for clinical management and oversight. Review Stat is a robust case management infrastructure optimized for the proactive case manager that creates bottom line results in today’s competitive case management environment.

The need for results and information from clients has placed a premium on an application that can deliver on these market demands.  Review Stat’s technical architecture provides flexible implementation options for maximum productivity and low maintenance.

Case management is a complex process that requires the collection and integration of data concerning patients, payers, employers, providers and other parties.  Review Stat enables case managers to focus on their patients and provide the most effective oversight by automating the required administrative tasks.

ICS uses a variety of medical references and resources that are loaded into the ReviewStat case management software.  This creates a proactive clinical toolbox that the nurse case manager utilizes during the course of providing case management.  ReviewStat has a real time connection with the commercially available Disability Duration Guidelines such as ODG, meaning as those organizations update their guidelines, that update is passed along automatically whenever a case is updated in ReviewStat.

ReviewStat Browser

All medical, clinical and documents assets are available in real time to designated and approved stakeholders via the Review Stat Browser Module

ReviewStat Browser facilitates communication with its around-the-clock, real time access to the ReviewSTat Production System.

ReviewStat Browser provides a user with the ability to:

• Follow the medical and disability aspects of a case in real time
• Review disability guidelines by diagnosis code
• Communicate and interact with the assigned case manager
• Receive Auto Email Alerts to retrieve new First Report of Injury
• Review the medical payment history of a claim
• Retrieve and review medical documents attached to a claim
• Generate Management Reports on demand

Accountability – Creating Best Practice Services

ICS has a long history providing customized Integrated Cost Containment Service programs specifically to the Workers’ Compensation, Auto, Liability and Disability markets with demonstrated result and unparalleled services.  ICS distinguishes itself as a vendor partner who provides highly customized and flexible programs supported by outstanding customer service.

We always pledge to ensure the highest standards of performance; integrity, customer service and fiscal accountability in managing these services on behalf of our clients.

ICS believes in a cooperative approach to defining service programs with our clients, recognizing that both parties share a mutual interest in maximizing employee productivity, minimizing duplicate effort, and offering a work environment to its employees that fosters accountability and rewards results.

ICS strives to break down the barriers that often prevent clients and their vendors from reaching these mutual interests.  These barriers often result from disconnected systems, conflicting workflows, and financial incentives that separate the two parties from aggressively pursuing these goals.

The demands placed upon companies operating in today’s business environments include risks of broader dimensions than previously imagined or encountered. We are ever mindful of the challenges that are before us and that prompt us to continue to deliver our finest efforts to meet the demands and needs of our clients.

We are constantly evolving, innovating and maturing, and we have a long track record of responding to and improving with competition.  We believe that we are better positioned today than we have ever been to continue to deliver quality and excellence.

The key to our success can be found in the nature of our business relationships. In building collaborative relationships with our clients we believe that we are placing our focus where it is most essential. Our strategy has always been centered on the concept of teaming with companies that continually strive for enterprise excellence and improvement.

Consistent with our corporate culture, we have continued to innovate within the context of our services and program delivery and management.   We have created significant electronic and real time interfaces where none previously existed, created new reports, benchmarking ourselves against industry and national standards, and have developed a strategy and format to establish various “Client Best Practices”

An example of the “Client Best Practice” philosophy and business rule ICS follows is the responsibility of protecting our client’s data.  ICS technology and workflow is SOC Type II Audit/SSAE 18 certified.  The ICS organizational structure contributes to the control environment by defining specific areas of responsibility and reporting lines.  The reporting structure seeks to maintain a proper separation of duties between positions so that internal control is not compromised.

The ICS Chief Operating Officer is closely involved in the daily business operations of ICS.  Managers are defined for each of the functional areas and all functional department manager’s report to the Chief Operating Officer who reports to the Present & CEO.

Our hiring practices are designed to ensure that new employees are qualified for their jobs.  Personnel are hired and developed to have the competence and training necessary for their assigned level of responsibility and the nature and complexity of the organization’s business.  Licenses and certifications, where appropriate, are validated as part of the hiring process.  Reference checks are also performed for all employees.  Continuing education and maintenance of licenses and certifications is tracked and reviewed by the Chief Operating Officer.

Training of employees is accomplished through supervised on the job training, seminar, and technical courses.  ICS has created a training program that includes online tutorial for all staff, inclusive of those staff that will be part of a dedicated client’s team.  ICS has developed clearly defined job descriptions and responsivities, and job performance is evaluated by management annually.

ICS has documented and provided each employee an employee handbook and we require every employee to sign a confidentiality agreement and an intellectual property agreement upon being hired.  These agreements help ensure that employees understand their individual roles and responsibilities concerning processing and protecting of confidential data and information.

In addition, it should be noted for each client, a client specific Process and Procedure User Guide is developed to be used and maintained by the applicable ICS team members.

ICS management regularly review the risk that may threaten the achievement of the company objectives.  This is performed as part of regular management meetings.  The management team is active in the industry and regularly monitors trends, change in laws and regulations and their potential impact on the organization and our clients.  If risks are identified, updates to control activities are implemented by the executive team.

Physical access to the ICS office in Piscataway NJ is controlled using key card and key lock on the office doors.  Access is limited to authorized ICS employees and their guests.

Access to any of the ICS web based applications, inclusive of SmartAdvisor, CEP, and SmartReports is controlled through notification to the Chief Operating Officer and/or the Manager of Medical Bill Review, Client Services or Administrative Services, where a determination to approve the request is made.  If the request is approved the User record is established and controlled by one of these ICS individuals.  The application access rights are granted based on the principle of least privilege for all applications and access is based on the job duties of the applicant.

To access the applications, users must first authenticate to their computer desktops.  The users then log into the application using a User ID and Password combination.  User with Administrative privileges are limited to individuals who require those rights.

Results – Taking Performance Measurements to the Next Level

ICS considers the evaluation of its services to be an integral part of any program we implement.  Performance is evaluated in a manner that meets the needs and requirements, of each of our clients while adhering to any methodological, data or system constraints.

We believe that performance measures should hold a vendor accountable for those activities they have control over.  ICS recommends the creation of a Quarterly Claims Review Committee whose goal is to review of the various Stewardship Reports to analyze Outcomes, Trends, Goals, and Program Enhancements.

Ad Hoc Reporting

In addition to the canned reports we customize for our clients that are generated directly by ICS, or for those clients that chose to do so, directly from their own internal resource.  Through the Report Builder Module of SmartReports, customers may design their own reports that are produced either on an ad-hoc basis or on a regular subscription basis.

Custom Reports are a combination of reports created by both ICS and clients using the Microsoft SQL Server Report Builder tool. These reports are run using published data pulled from the reporting database, which is refreshed nightly

Report Builder is a tool developed by Microsoft that allows users to create and design custom reports generated from the published data in the reporting database (also known as the Online Analytical Processing exported (OLAP) database). This allows SmartAdvisor clients to design reports that meet their business needs using an easy‐to-use drag‐and‐drop functionality that produces reports in various formats.

Stewardship Meeting and Reporting.

ICS considers the evaluation of its services to be an integral part of any program we implement.  We believe that performance measures should hold a vendor accountable for those activities they have control over.  ICS recommends the creation of a Quarterly Claims Review Committee whose goal is to review of the various Stewardship Reports to analyze Outcomes, Trends, Goals, and Program Enhancements.

We have provided examples of metrics that are typically measured, reviewed and discussed at the Quarterly Meetings.