Transcript Document

Managing Growth
Successfully
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POMCO Group Overview
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Company Overview
Membership
Services
Market
Operational Team
POMCO Group Quick Facts
• Established in 1978
- Founded by Maurice and Robert Pomfrey
- Approximately 400 employees today
• Over 400,000 members nationally
• One of largest privately held administrators nationally
• Average client tenure exceeds 10 years
• Manage over $1 billion in premium equivalents
• Office locations
- NY: Syracuse, Albany, Buffalo, Binghamton,
Rochester, Watertown, NYC, White Plains
- TN: Chattanooga
- CA: Central Valley, and adding other local staff
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- NV/CA: Western Region hub
A Diversified Services Company
Clinic
Services
Insurance
TPA
Services
POMCO
Group
Network
Services
Risk
Management
BPO
Services
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Why POMCO Group Is Unique
• Diversified services company,
highly differentiated value proposition
• Strong experience with both labor
and private-sector commercial business
• Management experience with CA, Blue,
Carrier and TPA environments
• Western region commitment, investment
including M & A interest
• Network expertise
• Risk-taking capabilities via owned insurance entity
• Broad workers’ compensation expertise
• BPO business segment/exchange launch
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POMCO Group Service Array
Offer a full range of product/service suites built around self-funded and
fully insured administration. Primary elements include:
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Medical (competitive provider networks from access and
discount perspectives)
Pharmacy (multiple PBMs with flexible service components, competitive
networks, full transparency and flexible rebate/discount models)
Ancillary products, including dental, vision, and short-term
disability/disability income
Flex/consumer Directed, e.g. FSA, HRA, HSA (option to have with or
without debit card)
COBRA, HIPAA administration
Consolidated enrollment and group/individual billing
(POMCO Group and other coverages)
Workers’ compensation
POMCO Operational Model
Our Promise.
(What we commit to do.)
Promises are the cornerstone of our success. Our ability to
keep the promises we make:
• Reinforces our commitment to our customers, our
community and each other.
• Relies upon our integrity, our passion and our industry
expertise to keep our promises.
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POMCO Operational Model 3P’s
Includes objectives that will measure POMCO
Group’s efforts to be a great place to work and
the development of our people.
Includes objectives that will measure our
ability to perform as an effective partner to
our clients. It also measures the
effectiveness of our vendor partners.
Includes objectives that will measure
our financial performance.
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Client and Member Service
Structured PMO implementation methodology via shareable project
framework
Real-Time Operational Metrics
Visual Dashboard Representation Across Functional Areas
Tiered Daily Stand-up Meetings
Imbedded Lean and Six Sigma Practioners within Value Streams
Account management, medical management, customer service and claims
team specifically trained on the client’s health plan(s)
Unique customer service number to dedicated unit
One call resolution
Dedicated 800 #
Average employee tenure is 8 years
Average client tenure is 10+ years
Adhere to top-tier service metrics
Certified “Top 100 Call Centers”
National service capability and hours of operation
Multi-lingual member services
Diversified Client Base
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2013-2014 Operational Challenges
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Q1 2013 - QicLink 3.30.30.35
Compliance (5010, PPACA, ICD10 pre-requisite)
Technology Missed Opportunities
• SQL database, Exception Processing, Plan Building
GUI, Bug Fixes
Anticipated Membership Growth (NYS Exchange: Health
Republic Insurance)
Control Costs
Required weekend cutover
QicLink 4.20 Upgrade
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POMCO Group #1 Initiative in 2013
• 4 Month “Go Live” Initiative
• 45 internal resources
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TriZetto Group Support
• Project Manager – Stephen Weir
• Technical(conversion, environment build) – Rodney
DeClerk
• Training – Rose Newell
• Custom Code Updates
• Citrix Application Server Load Balancing Enhancement
– Ron Gripon, Lifeng Xu, Richard Frazier
• Post Go Live Support to resolve response time issues
QicLink 4.20 Benefits
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5010 Compliant
PPACA Compliant
Pre-requisite for ICD10
Bug Fixes
SQL database – improved data warehouse run from 10
to 4 hours
GUI Plan Builder – GUI Format results in
• Improved Quality  Re-work Reduction
• Productivity  Simplified Troubleshooting
Increased system availability for claims production each
day by 6 hours
NY State Exchange
Back-office administrator.
• Medical claims adjudication and payment
• Customer service
• Medical management (UM/CM)
• ID Cards
• Stop Loss
2014 Enrollment
• Planned for 30k
• Reached ~140k
2014 Weekly Claim Volume
• Planned for 6k
• Actual ~32k
2015 Annual Enrollment
• planning for 280k
2015 Annual Claim Volume
• Projected @ >3M
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NY State Exchange Challenges
State Exchange presented unique challenges compared to
our typical business model:
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Requirement to track Primary Physician
Shared accumulators with multiple vendors, requirement
for visibility into claims/accumulator details
Plans required deductible to apply before Copay
Systems ability to scale with increased enrollment
Challenge
Participating provider selection and
application of correct benefits
An online solution was necessary to satisfy the need of
nearly two-thirds of the affected customers.
• Members who elected the covering plans were required
to select a primary physician prior to having services
rendered to avoid a co-pay.
• Member was not limited to changes or specialty within a
plan year.
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TriZetto Solution
Participating provider selection and
co-payment mapping
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Plan designs included plans with both optional and
mandated Primary Physician (PP) selection. The plan
designs dictated a zero dollar copay for an office visit
when a member goes to their PP. Our Plan Building team
worked with TriZetto to find the best solution that would
meet the requirements.
The Plan Building team and TriZetto recommended use
of the HMO module.
It was a simple process to install the HMO module and
TriZetto also provided onsite training.
Housing the participating provider data in Qiclink
provides us with accessible data for customer service, ID
Cards and reporting.
Challenge
Shared Accumulators
Plan designs dictated the ability to share accumulators for
out of pocket and deductibles between medical claims and
at least the PBM, but also potentially vision and other
vendors.
Customer service required visibility into the details behind
the accumulators, i.e. the pharmacy claims must be visible
to POMCO Group’s customer service staff, not just the
current accumulator value.
System must be robust enough to handle overage
reporting, enrollment matching, plan year rollover, and
other functional challenges.
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TriZetto Solution
Shared Accumulators
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The POMCO Group Pharmacy interface team performed a
gap analysis on the TriZetto ZPBM program and
recommended that POMCO Group proceed with
implementation of a customized version.
POMCO Group now receives daily pharmacy claims files
that run through this program and produce claims which
keep shared Medical/Pharmacy deductible and out of
pocket accumulators in sync.
TriZetto provided support to the POMCO Group team
during testing and QA, as well as ongoing product
support.
Challenge
Appropriate application of deductibles and
co-payments
System had to account for deductible payments ahead of
co-payments.
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TriZetto Solution
Appropriate application of deductibles and
co-payments
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In QicLink, a copay is always taken first and then the
deductible applies. Plan designs required that the deductible
must be met first, and then the cost sharing copay or
coinsurance is applied to the remainder of the allowed amount.
The POMCO Group team worked with TriZetto on a workaround, however, they had an adverse affect on claims
processing and/or claims related extracts.
The POMCO Group team proceeded with requesting a TriZetto
custom enhancement to provide the needed functionality.
TriZetto met the timeline and delivered the required
enhancement as an easy to install upgrade.
This enhancement was a must have as the services impacted
are commonly utilized services like office visits, lab and
surgery.
Challenges and TriZetto Solutions
Despite unusual challenges presented, TriZetto was able to
provide solutions.
Each solution has provided claims and customer service
staff with the tools and data they need to efficiently
perform their jobs.
With support from TriZetto, POMCO Group was able to open
customer service lines ahead of schedule and perform all
contracted services despite the unprecedented enrollment
More to come in 2015….
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2014 TriZetto Current Initiatives
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QicLink 5.0 Upgrade
Automation Review
QicLink Total System Review
BPO Claims Processing
ClaimsExchange Implementation
Medicare COB Enhancement
QicLink User Group Member
Thank you.
Questions?
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Confidential
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Copyright © 2014 TriZetto Corporation