For Healthcare Solutions, which delivers integrated medical cost management solutions to more than 750 customers in the workers' compensation and auto/PIP markets, those integration challenges were not only met, but far exceeded. In fact, the Atlanta-based company's impressive growth since its launch in 2007, has been driven primarily by innovation in the effort to help clients solve the problems of managing and reducing workers' compensation and auto/PIP medical costs.
Comprised of three subsidiary companies -- Cypress Care, ScripNet and Procura Management -- Healthcare Solutions has used a tradition of ongoing innovation to emerge as a market leader, according to Joe Boures, Healthcare Solutions' president and chief operating officer.
"Innovation tied to product development is not only encouraged within our workforce, but it has served as our primary focus for clients," Boures said. "For example, in just six years, the company has launched several first-to-market products while growing our business simultaneously."
With its growth clearly on the upswing (more than 25 percent compounded annual growth rates and annual revenues exceeding $360 million), Healthcare Solutions offers clinical- and technology-based services including pharmacy benefit management, specialty healthcare services, PPO networks, medical bill review and case management. Every product area across Healthcare Solutions' operating divisions has its own story about how innovation and product development has fueled overall success.
In its pharmacy benefits management entity, Jim Andrews, executive vice president of pharmacy services, pointed to several critical initiatives focused on industrywide pharmacy issues that the company has addressed, such as the management of paper bills (especially those from nontraditional billers), and clinical utilization programs, such as the monitoring of morphine equivalent dosing and the use of acetaminophen in prescription combination products.
Through the company's Rx360? program, Healthcare Solutions is producing average penetration rates of 97 percent for all pharmacy-related spend due to its unique management of nontraditional billers and its unique paper bill process. In addition, results from the company's acetaminophen effort also indicate a 54 percent decrease in claimants receiving more than four grams of acetaminophen, which is the at-risk daily dosage level.
"In each of these areas, we go above and beyond what a typical PBM delivers," Andrews said. "We cover every base, from out-of-network billing to clinical controls. Our efforts in reducing paper bill leakage, for example, have shown strong results."
Within the specialty area, Eileen Ramallo, executive vice president of specialty healthcare services, said that with ancillary services, which include durable medical equipment, home healthcare and other related areas, the challenge has been managing wildly differing prices for the same products or services, as these services have not historically had the rigor of billing that occurs within other service areas.
"In pharmacy, there is a unique code associated with every drug, but that type of one-to-one coding system doesn't exist for equipment and supplies," she said. "So we designed our unique catalog to systemically manage all products and services in a consistent and cost effective manner."
We used technology to build a proprietary product substitution process, similar to how formularies are used in pharmacy, that looks for products and services that are not only the most cost-effective, but also equivalent for medical efficacy, she said. Ramallo called it "bringing value to the supply chain process," and it has led to a dramatic turnaround in ancillary care cost management.
Another critical innovation is Healthcare Solutions' DME 360 program, which increases program penetration and savings rates by retrospectively applying discounts to bills that historically would be paid at either fee schedule or usual and customary rates. Through electronic integration with client bill review systems, Healthcare Solutions identifies and re-prices bills that were not prospectively referred to its program to apply discounts below state fee schedule or U&C reimbursement rates for in-network providers per the terms of their agreement with Healthcare Solutions.
"Our use of the DME 360 process was an innovative first-to-market product," she said. "You might call it putting order on chaos."
Three other product areas that benefitted from the merging of companies were in the company's managed care operations, which includes PPO, bill review and case management.
Nicole D'Ettorre, senior vice president of network services, explained that the PPO department has grown to three times its initial size since Healthcare Solutions' creation, morphing from a regional network entity in the Mid-Atlantic into a national network. D'Ettorre cited customer service as the company's leading success factor. And while that may not sound that innovative on the surface, she said that fast-growing companies can lose focus on that very critical area.
"Our customer service efforts for both clients and network partners have kept up with our fast-paced growth," she said. "We focus on delivering world-class customer service via collaboration across our different business units."
Jeffrey Sommerfield, vice president of medical bill review, joined the company two years ago and immediately began the move to a paperless environment. Within the past 18 months, Healthcare Solutions has effectively reached that objective.
"Innovation within medical bill review over the past 18 months has been tremendous," Sommerfield said. "Today, we can receive a bill in any form or fashion, from clients or providers. Whether they send us paper and we scan it in or we lift data from their systems; on our side, everything is paperless."
The main benefit, he explained, is that it still allows clients to choose their data delivery format, but the paperless aspect is completely transparent to them.
The process makes it easy for anyone submitting bills, which results in a richer, more effective bill review process.
"It doesn't matter what they have in terms of the bill format," he said. "In combination with the personal touch we add to the process, it's a very effective way of doing bill review."
On the case management front, Tina Downey, senior vice president of managed care, said the synergy between the Healthcare Solutions entities has driven quality throughout the organization. For example, capital investment allowed the managed care department to achieve a URAC accreditation, a critical indicator of meeting national quality standards.
"When the merger happened, it truly gave us every tool in our belt to help customers," Downey said. "We are more robust, with more diversity in developing new products and solutions for our clients."
Downey added that since 2008, the unit has experienced 100 percent top-line revenue growth.
"When you look at our talent pool--combining the resources of some very tenured, experienced professionals with seasoned leaders--it's clear why Healthcare Solutions has been such a success in the past several years," said Downey.
(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspective was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Perspectives can be found on our Web site at www.riskandinsurance.com/.)
May 1, 2013
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