Appendix:
Complementary Solutions
Engage Employees in Their
Health and Well-Being
Health Advocacy
• Personal Health Advocates help members
navigate healthcare and insurance-related
issues, quickly and efficiently
• Personal Health Advocates are typically
registered nurses, supported by medical
directors, benefits and claims specialists
• Single, ongoing contact available for, direct
dial phone number and email
• Increases employee productivity,
satisfaction and retention; maximizes
benefits utilization
• Available to members and their eligible
family members including
spouses/domestic partners, dependents,
parents and parents-in-law.
• Reduces grievances and appeals; improves
administrative efficiencies; alleviates burden
on HR staff
• Reduces medical costs; improves health
outcomes; saves everyone time and money
Wellness Program
•
•
Highly personalized program to help
•
Robust online resources support coaching
employees reach health goals
•
Innovative engagement programs,
campaigns, wellness competitions
•
Comprehensive, turnkey communications
and educational materials
•
Individual and aggregate management
reporting
•
Full suite of complementary add-on
solutions
•
Seamless integration with Health Advocacy
service and all other Health Advocate
solutions
Unlimited health coaching by phone, email
or secure web messaging
•
Key focus areas include weight
management, fitness/exercise, nutrition/diet,
stress management, tobacco cessation, self
care of chronic conditions
•
NCQA-certified Health Risk Assessment
and personalized report
EAP + Work/Life
•
Licensed Professional Counselors provide
confidential, short-term assistance
with personal, family and work issues
•
Counseling focuses on coping strategies
•
In-person, telephonic and online video
counseling available
•
Referrals to appropriate professionals for
more long-term support
•
Work/Life specialists locate support services
and local resources for help with childcare,
eldercare, legal and financial counseling
•
Work/Life website, webinars and onsite
seminars
•
Unlimited telephonic consultation for
management and supervisors for help with
critical incidents, employee conflicts and
sensitive cases
•
Medical Bill Saver™ service features skilled
negotiators for help lowering non-covered
medical/dental bills
•
Personal Concierge service
•
Reduces need for more costly mental health
services and ER utilization
EmpoweredHealth™
• Strategic alliance of key programs and
services into one seamless offering
• Single, toll-free number, no matter what the
issue
• Delivered by a select team of
interdisciplinary experts in one location
• Advanced systems architecture analyzes
health data from multiple sources; enables
powerful targeting risk stratification and
customized coaching
• Integrated Dashboards provide
consolidated view of benefits utilization,
gaps in care, health/wellness measures and
engagement opportunities
• Promotes unprecedented level of
collaboration around each individual
• Targeted, multi-format communications
• Robust management reporting
• Improves health outcomes/productivity;
decreases medical costs; maximizes
benefits utilization
Chronic Care Solutions
• Fully customizable to meet each client’s
specific needs
• Advanced data analysis identifies and
stratifies employees by risk level (high,
average, low) and co-morbidities
• Ongoing, customized prevention and
condition-specific communications increase
compliance with recommended care
• Unlimited access to a Registered Nurse for
personalized coaching
• Flexible communications including
telephonic and email
• Reduces utilization and costs associated
with avoidable complications
• Improves health outcomes and quality of
life; lowers medical costs
• Fully integrated with Health Advocacy
service and all other Health Advocate
programs
Onsite Biometric Screenings
• Customizable onsite health
screenings available nationwide
• Complete program management
from start to finish
• Wide selection of screening options
and packages
• Delivered by trained Health
Advocate registered nurses, EMTs
and health educators
• Easy-to-use online scheduler
• Immediate results
• Turnkey educational and
promotional materials
• Seamless integration with Health
Risk Assessment (HRA), wellness
and incentive programs
• Individual and aggregate year-overyear reporting
Health Cost Estimator+
•
Health Advocate’s proprietary pricing
•
benefits status
transparency solution
•
Supported by leading-edge technology and
•
Provides key information to help select the
•
Multiple data sources including client’s paid
•
Empowers more cost-effective decision-making
medical claims supplemented by our national
•
Available on multiple platforms including
database
•
Proactive employee awareness and
engagement program
highest-value providers
•
Quality indicators, safety scores and patient
reviews
data analytics
•
Real-time out-of-pocket estimates and user
Cost comparisons for hundreds of medical
services by ZIP code
mobile, tablet and PC
•
Employees can call a Personal Health for
added pricing support
Personalized Health Communications
• Personalized preventive and chronic care
reminders focused on gaps in care
• Data-driven using eligibility and claims data
matched to evidence-based guidelines
• Reaches 100 percent of members with
preventive and chronic care services due
• Promotes compliance with important tests,
medications and other screenings
• Addresses the most costly conditions such
as heart disease, diabetes and asthma
• Directs members to their personal
physician, Personal Health Advocates and
Nurse Coaches
• Comprehensive management reports
• Fully-integrated with all Health Advocate
solutions
Incentive Management
Participation-Based
Outcome-Based
• Engage with a Wellness Coach
• Outcome-based associated with health-
• Complete a workshop
contingent program
• Complete a PHP
• Behavior change
• Track activities + participation on Wellness
• Improve screening results
website
• Quit tobacco
• Communications support
• Eligibility file generation
• WPC/Consultation and planning
• Incentive tracking + reporting
• Added fees
• WPC/Consultation and planning
Healthy Baby
• Personalized program focused on
education, support and helping
members have healthy pregnancies
and babies
• Identifies risk factors (e.g., smoking)
and supports members in reducing
health risks
• Ongoing, regular outreach throughout
pregnancy and after delivery
• During pregnancy: Ensures women
get prenatal care, understand
maternity benefits, and have a
resource for any complications
• After delivery: Ensures that the baby
gets newborn care; screen mom for
post-partum depression; offers
benefits and claims support
• Improves health outcomes and
reduces medical costs
Outbound Calling, Text and Email
•
Employs a variety of communication
•
methods to fully support your need
•
CSAT Customer Satisfaction rate of
97%
Product adoption, adherence and
•
Enhanced patient engagement
retention
•
Improved health & wellness
•
Increased revenue and market share
•
Proven customer satisfaction & loyalty
Tobacco Cessation Program
• Comprehensive solution helps
employees successfully quit tobacco
and stay tobacco-free
• 12-week, evidence-based program
• Personalized, one-on-one coaching
• Engages spouse in Coaching for
additional support
• Coordinates with employer or health
plan-paid Nicotine Replacement
Therapies
• Integration with Wellness incentive
program
• Promotion and reinforcement
materials
NurseLine
• 24/7 hotline staffed by experienced Registered Nurses
• Supported by a state-of-the-art clinical information database
• Addresses questions about symptoms, medications and treatments for
acute health issues
• Provides easy-to-understand self-care measures for non-urgent issues
• Directs callers to appropriate care in emergency situations (urgent care,
911)
• Ongoing communications support
• Integrates seamlessly with Health Advocacy service
MedChoice Support™
•
•
•
Self-directed comparison tool guides
employees through key health decisions
about treatments, tests and medications
Combines authoritative medical
information with practical
personal assessments
150 decision-making topics cover costly
and high-prevalence health choices such
as surgery, diagnostic tests and
medications
•
Downloadable summary to share with
healthcare team
•
Helps employees choose appropriate
care that may be less risky, complicated
and costly
®
Cleveland Clinic MyConsult Online
Second Opinion Program
•
Special arrangement with Cleveland
•
Helps confirm diagnosis or a
treatment plan or offers alternatives;
provides recommendations
•
Convenient and secure; all personal
health information is kept
confidential
•
Maximizes employee engagement in
their care
•
Improves health outcomes and
reduces medical costs
Clinic for access to electronic second
opinions through their MyConsult Online
Medical Second Opinion program
•
Designed for employees with serious
and life-threatening medical diagnosis
•
Provides access to the Cleveland
Clinic’s expert specialty physicians
•
Eliminates time and expense of travel
Reduce Medical Costs –
Save Money
Data Analytics
•
Comprehensive selection of analytics and
•
productivity
reporting services
•
Flexible, customizable and scalable solutions
•
•
Provides key insight into the cost and quality of
health benefits programs
•
Helps monitor success of disease
management and wellness programs
Completely objective; no affiliation with specific
carries or plans
available to self-insured groups of all sizes
•
Measures the cost of absenteeism and lost
Proven performance measurement methods to
facilitate data acquisition/consolidation
•
Customized reporting with multiple end-user
views
PreVent/Claim Overpayment Recovery
• Complete post adjudication, pre-payment
• Uses predictive, data-driven, integrated
identification/validation solution
code edits and clinical aberrancy rules to
supplements auto-adjudication and
identify potential mis-payments
traditional pre-pay tools
• Combines analytics with the human touch
to identify areas of incorrect payment before
the payment is made to the provider
• Increases recoveries and reduces costs
immediately
Cost Containment Solutions
•
State-of-the-art data analytics,
•
combined with expert knowledge, to
pinpoint claims payment errors and
complete case management
•
identify areas of waste
•
Highly-trained staff works to recover
Skilled recovery specialists provide
Supported by expert legal team and
resources
•
mis-paid claims and implement
Clients pay only if our services can
save them money
processes to protect future incorrect
payments
•
Ongoing, comprehensive client
reporting
HealthInsights Dashboards
•
Helps employee benefits
•
organizations transform aggregate
claims, pharmacy and enrollment data
health and wellness benefits costs
•
into a series of understandable web-
Predictive modeling based on
evidence-based medicine cost and
utilization history
•
Quickly identify and track spending
Select and manage insurers and
health plans; monitor financial and
based dashboards and reports
•
Track, measure and forecast enrollee
clinical performance
•
Eliminate redundant costs and
improve product offerings
Subrogation/Overpayment
Recovery
•
Proprietary subrogation identification
•
model and advanced analytics identify
third-party liability and claims with the
verify that the claim is truly overpaid
•
greatest likelihood of recovery
•
Applies specialty subrogation tools
(property/casualty database searches,
federal/state online records) to
maximize identification and recovery
Validators manually calculate and
Regular, detailed reporting of claims
recovery status and results
•
You only pay us if we save you money
Third Party Liability
•
Proprietary software, combined with
Code library contains codes that most
expert team, analyzes claims to
often represent accidents that result in
identify when other sources for
settlement; library is updated annually
healthcare coverage may be liable for
•
•
•
Minimizes member abrasion and use
claim payments
of client’s internal resources, and can
Software uses ICD-9 trauma and
be incorporated into any payer’s
E-series codes to identify and
workflow
accumulate paid claims
Survey Services
•
Coordination of Benefits (COB) Recovery. Experienced survey team
collects, manages and reports other insurance coverage information for
member populations; results uploaded to payers’ systems so claims can be
processed accurately according to the primary sequence.
•
Employer Group Size Verification. Helps payers maintain compliance with
Medicare Secondary Payer (MSP) requirements to ensure accurate claim
payments and avoid fines/penalties.
•
Social Security Number Capture. Survey services ensure compliance with
ACA mandate to capture Social Security numbers of members who carry
minimal essential coverage.
Medical Bill Saver™
• Negotiates non-covered, out-of-network, and/or exceeding the
benefit maximum medical or dental bills over $400, regardless of
benefit status
• Highly experienced negotiating unit
• Offers “safety net” for employees to reduce out-of-pocket expenses
• Track record of achieving significant savings
Medicare Advantage Stars Program
• Fully integrate 6-part program helps plans meet quality-based objectives
• Provides opportunity to earn 5-star rating required to secure millions in
bonuses and ability to market the plan year-round
• Combines personalized, telephonic, healthcare help, clinical coaching, datadriven communications and Dashboard technology to increase compliance
and improve outcomes
Telemedicine
•
Licensed MeMD physicians available
•
24/7, 365
•
No waiting rooms, no closed offices,
typical office, urgent care or ER visits
•
no waiting weeks for an appointment
•
Receive answers and treatment within
30-60 minutes via phone or video
•
No limitations on use
Significantly less expensive than
Saves on out-of-pocket expenses, i.e.,
deductibles, co-pays
•
Less time off from work for doctor
appointments
Support Streamlined
Administration
Benefits Gateway™
• Benefits experts connect employees
to all benefits through a single 800#
(e.g., medical, dental, EAP, pharmacy)
• Flexible design; client dictates which
benefits/vendors to include
• Health Advocate development team
coordinates intra-vendor setup and
processes
• Supported by the latest
information/telephonic technology
• Turnkey communications program
• Smooth transition to Health Advocacy
service for help resolving healthcare
and insurance-related issues
FMLA Support
•
Staffed by a team with experience
Helps determine whether the condition
working with providers, health
meets the FMLA definition of “serious
benefits, medical issues and FMLA
medical condition”
review
•
•
•
Fully complies with HIPAA privacy
Reviews employees’ medical leave
regulations to protect health
requests, including contacting the
information
certifying physician when necessary
External Appeals Administration
•
Independent, turnkey solution to meet
federal regulations for external appeals
•
Seasoned healthcare and insurance
experts manage complete external
appeals process
•
Contracts with qualified Independent
Review Organizations for unbiased
reviews
•
Develops required member notices, in
accordance with NAIC model
communications
•
Facilitates expedited reviews where
member’s life or health is at risk
•
Coordinates relevant medical and
benefits information
•
Tracks progress; provides required
reports including certification
of outcomes
Enrollment Advocate
•
Serves as primary resource for all
•
benefit-related questions
•
Supports HR staff and strategic
communication program
•
initiatives
•
Enhanced support to make
presentation of benefits run smoothly
Supports all aspects of
Employees can call any time; no limit
on call duration and call-backs
•
Seamlessly integrates with Health
Advocacy service
Independent Appeals Administration
•
Supports self-funded organizations
who have fiduciary responsibility for
the appeals process
•
Experienced appeals administration
and review team performs objective
analyses for accurate appeals
decision
•
Researches appeals to ensure fair
and consistent treatment and avoid
costly mistakes
•
Manages the entire process; provides
unbiased evaluations
•
Ensures compliance with state and
federal regulations and timelines
Improve Quality of Care
Integrated Data Repository
•
•
•
Customizable services include patient
outreach, administrative assistance and
data analytics to help health
organizations maximize revenue,
optimize patient engagement and build
brand loyalty
Personalized service from trained
Personal Health Advocates
Administrative and clinical help for
patients and staff; personal outreach to
patients via telephone and mail
•
Advanced data analytics and reporting
helps identify risk and pinpoint spending
•
Frees physician and administrative
schedules
•
Maximizes performance on quality metrics
and revenue retention
•
Fully integrated with all Health Advocate
programs
Disease Stratification and
Predictive Modeling
•
Identifies and risk stratifies patients
Actuarial forecasting uses industry-
with chronic diseases using
leading predictive models, customized
proprietary clinical indicators adapted
to include multiple data sources
from nationally-recognized standards
of care and evidence-based medical
guidelines
•
•
Creates member-level risk scores,
broken down by service category and
2,000+ clinical classifications
•
Comprehensive concurrent and
prospective healthcare cost and
utilization analysis
Provider Performance Analytics
•
Tailored approach to managing
performance, quality and cost efficiency
among provider populations
•
Flexibility—client decides how strict or loose
the methodology
•
Analyzes episodes of care to rate providers
on effectiveness and cost
•
Identifies unnecessary medical
interventions
•
Analysis based on peer-reviewed
preventive and recommended care metrics
•
Data is refreshed annually and presented in
actionable formats to promote behavior
change
•
Results can be used to develop preferred
networks to control costs and improve
outcomes
•
Detailed, easy-to-understand reporting
package
Population Risk
•
Tailored approach to managing
performance, quality and cost efficiency
among provider populations
•
Flexibility—client decides how strict or loose
the methodology
•
Analyzes episodes of care to rate providers
on effectiveness and cost
•
Identifies unnecessary medical
interventions
•
Analysis based on peer-reviewed
preventive and recommended care metrics
•
Data is refreshed annually and presented in
actionable formats to promote behavior
change
•
Results can be used to develop preferred
networks to control costs and improve
outcomes
•
Detailed, easy-to-understand reporting
package