What is your objective for claim turn around time, processing accuracy percentage, and financial accuracy percentage?
Advantek's objective for claim turn-around time is 10 working business days or less. We strive to exceed 97% or higher for processing and 99% financial accuracy. We will be diligent in meeting or exceeding your expectations.
Confirm your flexibility for claims payment override. What is your record keeping system for overrides? How are they tracked?
Advantek's process and procedure accommodates authorized payment overrides. These overrides are flagged in our claims processing system and are tracked.
What fee schedule do you use for payment of claims?
Advantek's flexibility can accommodate multiple PPO fee schedules based on any methodology. Our standard Reasonable and Customary (UCR) is based on current year Ingenix MDR data.
When claims fall outside your service and price guidelines, what is your procedure prior to payment?
If Advantek receives a claim for services rendered that are outside our service and price guidelines for a covered enrollee, we will first determine whether this is a covered benefit under the terms of the plan. If the service would qualify for payment, we will pay the R&C rate for the service in the particular geographical area.
What are your guidelines for administration of subrogation?
Advantek has a contracted vendor to handle all subrogation claims. Data files are sent electronically for review and resolution. There is a staff of paralegals and attorneys that track all subrogated claims. Recoveries net of subrogation fee are promptly forwarded to you.
Describe your procedures for reporting, filing and recovery of specific and aggregate stop loss claims. What is the process for resolution of denied claims?
Advantek staff runs queries monthly for each stop-loss contract year. Each query is set at 25% and 50% of the attachment point (deductible). Reports are reviewed and patients are identified for 50% notification to the stop-loss carrier. Patients are also identified who have exceeded the deductible and required information is sent to the carrier for reimbursement. Files are maintained for each patient in addition to internal tracking logs for each carrier year. We also identify claims based on ICD-9 criteria.
Appeals are filed for all denials based on contract language. However, we currently have a very low denial rate and generally receive reimbursement for 100% of filings.
The Cost Containment Department handles all aggregate stop loss tracking.
Do you provide Utilization Management services?
Yes, currently, we are delegated for utilization management and reporting for many of our customers. Our UM services help ensure the following:
- Services are medically necessary and are delivered at appropriate levels of care.
- Authorized care matches the benefits defined in the member's plan document.
- Hospital admissions and length of stay are justified.
- Services are not over utilized or under utilized.
- Appropriate care is offered in a timely manner and is quality-oriented.
- Scheduling is efficient for services and resources.
- Costs of services are monitored, evaluated, and determined to be appropriate.
Advantek would like to extend our UR services to prospective clients, which would allow Advantek to better support, fully integrate and control costs.
Who are the Reinsurance carriers that have approved your organization?
Through various intermediaries, the following reinsurance carriers have approved Advantek:
- American United Life
- HCC Benefits
- KMG America
- Lloyd's of London
- Mutual of Omaha
- Optum Health
- Sun Life Financial
What is your audit procedure for determining payment accuracy percentage, processing accuracy percentage and financial accuracy percentage as defined above?
At Advantek we treat your money as our own and therefore have an extensive audit procedure in place. In addition, we perform a random audit of a statistically valid sample weekly.
How are errors found during an internal audit corrected?
Errors found during an internal audit are corrected accordingly prior to payment.
Provide the results of your most recent internal performance review showing the number of claims processed, error rate for payment and processing, turn around time, etc.
The results of Advantek's most recent internal performance review produced a score of:
- 100% of all claims paid in 10 days
- 98.99% Financial Accuracy
- 99.42% Processing Accuracy
Explain your process for handling overpayments, overcharges, excessive hospital confinements, unnecessary hospitalizations, and other treatments and procedures.
Advantek's UR department is extremely competent in recognizing and disallowing unnecessary hospitalizations, treatments and procedures. All hospital charges over $10,000 are sent to an outside vendor for a hospital audit. This audit identifies unsupported, unbilled and late charges. Advantek also aggressively audits claims and monitors overpayments.
Are inpatient hospital claims routinely audited?
Inpatient claims are randomly audited for every client. With Advantek's extensive internal resources, we can provide a thorough and effective traditional hospital audit procedure, if requested.
How are provider billings reviewed for arithmetic accuracy?
As claims are entered, the Advantek system automatically checks for arithmetic accuracy at multiple levels comparing itemized charges to total billed. The system requires that any inaccuracy be corrected before finalization of a claim.
What safeguards exist to protect against claim abuse and fraud?
Random and periodic chart audits and medical record reviews are preformed at Advantek to protect against provider fraud. In addition to following prospective clients policies, Advantek has established and maintained separation of duties. Second signatures are required on checks over an agreed upon amount. The Vice President of Operations also reviews 100% of check payments.
What are your policies regarding an outside claims audit and at whose expense?
Internal resources are provided by Advantek to assist outside auditors in the audit process. We prefer that the self-insured plan provide the auditor.
Describe your customer service process when an employee calls with a claim inquiry.
The Customer Service Representative (CSR) will take the following steps:
- Gather member data (such as ID number, etc.) and outline the concern
- Research the issue and respond to the caller
- Take additional steps to resolve the issue, such as placing calls to provider offices
- Reprocess the claim when appropriate
- Provide explanation of benefits
- Log the call for future reference
What was the average speed of answer for customer service calls in 2010?
All calls are answered within industry standards, 91.6% answered in 60 seconds.
What is the average number of weekly calls taken by the customer service department?
The current weekly average number of calls received by the Advantek customer service department is 1900.
How are customer service calls monitored and reviewed for accuracy?
The Advantek Customer Service manager randomly monitors calls on a daily basis. All notes, route sheets, claim request forms and research material are reviewed by the Manager to ensure accuracy and appropriate communication.
Who will be assigned to handle customer service inquires?
Specific Advantek customer service representatives will be responsible for prospective clients.
Claims Processing System
Describe your adjudication system vendor and architecture. Be sure to identify hardware, software (including current version being used, how long it has been in place, and any plans for upgrades), modules in place, number of terminals, etc.
LuminX is the software vendor supporting the Acclamation Systems, Inc. Luminx was founded in 1989. Luminx is an automated system designed for organizations entrusted with the responsibility of administering health and other employee benefits.
Describe your internal security controls for claim approval limits.
- New staff member claims are fully audited and dollar limited until the accuracy level is approved by an auditor. The dollar limit is raised as the processor achieves mastery for their level of processing. In addition, access is initially restricted to only processing professional claims, (HCFA 1500) and later allowed hospital claims (UB-92) processing.
- Advantek maintains separation of duty requirements (i.e., a person with payment authority cannot also have authority to alter eligibility.) Only the accounting department has authority to issue checks.
Describe your system's method for pending a claim for additional information.
Claims that are pending are put on "hold" in the Advantek system. Letters are automatically sent through our suspended letter program every 30 days to the member and provider requesting the additional information that is needed to process the claim. A weekly "pending report," which serves as a system diary, is reviewed twice weekly by lead examiners and follow-up is performed if necessary. Receipt of additional information is tracked by date stamping and is attached to the original claim.
How do you determine reasonable and customary (R & C) levels?
Advantek contracts with Ingenix (MDR), which provides R&C data including semi-annual updates.
Does the system automatically screen charges in accordance with the incurred dates in relation to the plan design changes?
The claims module of Advantek's system is date sensitive and will reference the appropriate historical period for support files, corresponding to the claim's date of service.
Our system allows for the capture of history for:
- Member's Eligibility Plan Assignments
- Plan Level Benefit Adjudication Rules
- Provider Contract History, & Provider Pricing History
- All Pricing Support Files
What edits and controls are used to avoid duplicate payments?
The Advantek system currently checks for duplicate claims (during the manual, auto adjudicate or electronic claims process) by comparing the following elements from a new claim against claims previously entered into the system by:
- Provider of Service
- Specific Dates of Service
- CPT Code
Does your system have the capability to store individual claims payments and batch them together for one weekly check/draft production and distribution?
Advantek's system is very flexible. Individual claim payments are batched together for a single check/draft. The individual payments are listed within a corresponding remittance advice, which is generated at the same time as the check.
How will you provide eligibility verification?
Benefits and Eligibility information can be communicated to participants and providers in the following ways through Advantek:
- Toll-free telephone number with message line
- Advantek has on-line access for participants and providers to support benefits and eligibility information
What is the system's capability for handling multiple occurrences of employee and dependent eligibility changes?
Unlimited employee and dependent eligibility history is maintained and stored. Additionally, other Advantek system functions are date sensitive, therefore referencing the correct period of eligibility for the appropriate processing factors.
Will the system generate form and free form letters and Explanations of Benefits (EOBs)?
Advantek's system supports a fully integrated Letter Module for the following letter types: Member, Group, Provider and Claims. The system has the capability of generating Letters/Correspondence on an individual basis, or 'in mass'. The system will keep a historical record of all letters generated.
The system also has the capability to produce EOB's by selecting the desired selection criteria.
Will the system generate separate and different EOB's for the beneficiary from the EOB for the provider?
Yes, Advantek generates different formats for the Member/Beneficiary and the Provider.
What is the process for notifying participants of denied or disputed claims?
Denials will appear on the EOB's and will contain ERISA wording for appeal processes.
Describe the procedures used for administration of Coordination of Benefits.
The Advantek system contains an automated COB claim-processing feature. Therefore, when a COB is identified, the other insurance amount is also entered electronically into the claim detail lines, the system will automatically adjust the line item Net Amount. The system fully supports COB and TPL processing.
The Advantek system also has a COB module that is accessible from the claims and eligibility modules, capable of capturing carrier information including effective cancellation dates, transfer to a new group, lapse in coverage and COB information at the employee and dependent level.
How would you inform clients of legal changes that could affect its Plan Document?
Advantek has a corporate attorney and a licensed document writer who can facilitate very open communication of any legal change.
What reports are standard, Frequency?
Management Report Packages can be customized by Advantek to support prospective clients' needs.
The standard report set will be determined by the client free of charge. Ad hoc reports and additional data analysis are available at negotiated rates. We would be happy to discuss additional services available from Advantek.
What is your typical banking arrangement with clients? Can clients use the bank of their choice? Do you have a preference?
Advantek is flexible in its banking arrangements based on prospective client's needs.