ICS_services overview_template

ICS - Integrated Services Total Service Solution Overview Prepared for :

Overview of Integrated Services Lines of Business: WC / Auto / FELA / Liability/ Group Health 24/7 Claim Reporting/First Report of Injury/Absence Mgmt Call Center Early Intervention Telephonic Case Management / Utilization Management EPO Network Management Pre-Authorization / Utilization Review Medical Bill Review – Online & Paperless PPO Fusion Specialty Nurse Audit & Out of Network Signed Agreements Independent Medical Evaluations Independent Physician Reviews Pharmacy Benefit Management & Durable Medical Equipment Programs Medicare Set Aside Medical Record Litigation Support Fraud & Investigative Services Proprietary web-based technology solutions

ICS - Integrated Services Overview Genesis of ICS Strategic Partnership with MCMC Disability and medical care management services Leader in technology-driven, early intervention case management services Extensive experience within both public and private sector, risk pools, carriers, third party administrators, self insured/administered, and transportation industry Comprehensive and innovative technology solutions, including extensive interface capabilities Documented savings and results Flexibility to customize all aspects of service to ensure programs meet unique needs of each client

Call Center Services - Component Benefit Promotes Early Intervention with prompt notification of injury, illness, accident and/or absence Dedicated Toll-free number available 24 hours a day/7 days a week Designed to complete all mandatory and client specific reporting forms Allows for immediate verification and access of information via Auto Email Alert process and WebOPUS Browser technology Designed to eliminate paper & labor intensive processes Improves timeliness of reporting of injury,illness, accident and/or absence, allowing for Care Management to begin immediately Provides for Mandatory and/or “Soft” channeling to appropriate PPO/EPO Network provider Provides for “Call ahead” process to the appropriate facility Provides for Flagging between various payment systems

For Client A, new injuries that are reported 8 Days of Greater incurred roughly 140% more in medical costs than those cases that are reported the Same Day. Average Medical Cost by Lag Time Category

Early Intervention Nurse Case Management/EPO Network Services

Early Intervention/Telephonic Case Management Component Overview & Benefits Prompt and concurrent review and management of the medical care of injured employees ensuring the utilization of the best and most appropriate medical care Timely and continuous contacts with injured employee, work site coordinator, medical provider, and claims adjustor until claim resolution promoting effective communication Focused return to work coordination by managing the disability duration of injured employees compared to national best practice guidelines Communication of Care Management Episodes to all interested parties via EDI with Claims System, Auto Email Alerts, WebOPUS ® Internet Browser, and Auto Fax Server Promote employee advocacy and goodwill

Early Intervention/Telephonic Case Management Upon completion of an Initial Assessment, Nurse Case Manager will evaluate: Medical Management • Treatment Plan • Disability Duration Return to Work Plan • Pre-Authorization/Utilization Review Necessity for Peer Review, Medical Evaluation or Field Case Management Continuously update work site coordinator, claims adjustor or any other interested party with care management milestones via: EDI to Claims System Email Alerts to all interested parties WebOPUS ® Browser accessibility

Monthly Saved Days Analysis - Comparison to National Benchmark For this national client, the average monthly “saved” lost time days has increased by nearly 200% over the past 2 full calendar years. The “saved” days is measured on closed Lost Time cases and the number of lost time days incurred measured against the expected disability duration using national best practice benchmarks

Transitional Duty Outcomes - New Employees Entering Program For this national client, since FY02, there have been over 1,700 new employees who have benefited from the Transitional Duty Program.

Average Lost Time Days by Lost Time Claim CY 1999 was full year prior to implementation of current TCM Program

Exclusive Occupational Health Network Overview Specially designed network of occupational health providers that are trained to understand and treat a work-related injury Occupational Health facilities that are in close proximity to employer locations Utilization of Occupational Health facilities that have gone through and met extensive credentialing criteria Utilization of Occupational Health facilities that have gone through and successfully met rigorous Site Visits Ongoing Site Visits are completed to ensure compliance .

Exclusive Occupational Health Network Overview Establishment of “Service Level Agreements” to provide an injured employee with the following “Expectations”: Expect to receive medical care within 30 minutes of arrival. (Remember: Emergencies should always go to the nearest ER) Expect that the facility be near the worksite, be clean and have the equipment necessary to treat their injury appropriately Expect that the treating medical provider should be able to answer your questions and provide you with information about your injury. Expect that the medical provider is communicating with your Nurse Case Manager to ensure you are receiving the best and most appropriate medical care Expect that the Occupational Health facility that treated your work related injury is also certified by Health Services to complete a Return To Work Physical. (If necessary, this ensures your Physical will be completed by a facility that knows you and your injury.) Expect to find a contracted Occupational Health facility via Intranet site or by calling the Call Center.

Pre Certification/Utilization Review Services

Utilization Review - Component Benefits Detailed determination reporting with complete clinical rationale and treatment guidelines used for decision making Seamless integration with Telephonic Case Management and Medical Bill Review Pre-certification Model Medical Necessity Review Full utilization management including concurrent review Physician Review Model Criteria based referral Peer to peer board certified specialties Independent Medical Evaluations Case Management Model Early Intervention Field Case Management as necessary Cost Projection

Medical Bill Review & PPO Fusion Services

Medical Bill Review Services Application of all state fee schedule/UCR values, jurisdictional rules, and CCI/OCE edits Access to multiple network/out of network fee discounts Specialty review services for additional savings Guaranteed turnaround times Real Time interface to share data with UR and case management services Dedicated toll-free provider assistance hotline Automated check writing

Medical Bill Review Components Claim Handling/Intake Mailroom Claim Indexing Document Management Adjudication Fee Schedule & UCR Application Nurse Code Review Nurse Desk Audit PPO Fusion Application Out of Network Bill Signed Negotiations Online Medical Bill Review & Approval Operational Throughput

Medical Bill Review – Service Overview Automated Client specific utilization management parameters Customizable claim edits for exception processing Access to multiple network fee discounts Application of State Fee Schedule/UCR values, State rules and CCI Edits Guaranteed turnaround time to enhance provider relations Comprehensive status & outcome reports including provider profiling Linked to WebOPUS case management software Electronic interface in sharing Closed/Denied information to prevent improper payments Electronic link with Group Health carriers to prevent “double dipping” Automated check writing capabilities Dedicated toll free Provider Assistance Hotline Mail Room outsource/claim indexing services Ability to offer an online Approval/Denial portal for Adjusters to make a decision on a scanned medical bill. Creating the “paperless” medical file.

PPO application performed on proprietary software platforms Setup customized per State for maximum penetration / savings Network types: National / Regional / Specialty No conflict of interest “ Fusion” technology - Competitive Advantage Increased savings through multiple network Tiers – Best in Class Immediate network application reduces “lag time” Increased penetration levels drive additional savings Client A has experienced a 58% improvement in PPO Savings Client B has experienced a 150% improvement in PPO Savings Client specific network solutions on a state-by-state basis through historical data analysis Quarterly Reviews of PPO Penetration and Trending Analysis to ensure PPO Tier is appropriate and applicable to current outcomes Network Solutions – The ICS Fusion

PPO/Specialty Savings & Penetration Breakdown Tier 1 % of Total Savings: 29% Tier 2 % of Total Savings: 8% Tier 3 % of Total Savings: 8% Specialty Network % of Total Savings: 22% Specialty Review % of Total Savings: 33% *Specialty Networks include PT, MRI, DME PPO Penetration Tier 1 PPO Bill Penetration: 21% Tier 2 PPO Bill Penetration: 13% Tier 3 PPO Bill Penetration: 9% Specialty Network Penetration: 23% Specialty Review Bill Penetration: 1% Total Bill Penetration: 67% PPO Savings Case study: National retail client with warehousing and distribution centers 2009 New Jersey Results: 75% PPO Penetration resulting in 50% Gross Savings

Transparent claimant, provider, and employer tool, customizable by client Consolidates all prospective services (pharmacy, PT, imaging, DME) into an ID card Created through a claim file feed or in real time through a customized web-site Incorporates panels to improve compliance and direction of care Increases utilization of prospective programs and PPO penetration, reduces out-of-network management cost Enhances quality of care and improve claim outcomes The ICS Health Ticket

IC_Solutions – Specialty Bill Review Services

IC_Solutions offers a suite of services to address the specialty bill review needs of Workers’ Compensation, Auto, Liability, Federal, Longshoreman, and Maritime payers These services, supported by innovative and proprietary technology, result in accurate outcomes for Code Review, Desk Audits, and Out of Network Negotiations with Signed Agreements that deliver significant savings to our clients. IC_Solution’s experienced subject matter experts have firsthand knowledge of provider billing practices and techniques. IC_Solutions Nurse Auditors and Certified Coders prevent overpayment of medical charges IC_Solutions – Specialty Bill Review Services

Code Review - Over $7,750,000 in Savings for CY 2009 RN review of coding and supporting documentation Review for linkage of Diagnosis Codes to Procedure Codes, along with confirming correct modifier usage Desk Audit - Over $3,500,000 in Savings for CY 2009 Focused Inpatient Hospital Bill Auditing by experienced Nurse Auditor Review for causal relatedness of charges to compensable injury, appropriate length of stay, and appropriate coding Out of Network Signed Agreements – Over $3,000,000 in Savings in CY 2009 Recommended referral criteria: Any medical bill that comes back without a PPO hit and over $2,500.00 in Charge Amount should be flagged for consideration Utilize proprietary application to identify past payment trends to establish appropriate negotiation baselines All negotiations are tied to a signed agreement by medical provider to ensure 0% reconsiderations Specialty Review/Negotiated Savings

HIPPO contains information on millions of medical transactions, including costs, charges, PPO hits, and prevailing payments. Queries can be based on individual bills or more globally by using Provider Tax ID Numbers IC_Solutions – Specialty Bill Review Services

Referrals to IC_Solutions for anyone of our services is the model of flexibility, including: *Secure E Fax *Secure FTP *EDI *Hardcopy *Email The entire body of work for all IC_Solutions services is managed and completed through proprietary web-based case management portal, WebOPUS. WebOPUS allows you real-time access to all medical and clinical information associated with a referral. WebOPUS allows for secure ongoing communication with the ICS Nurse Auditor and/or Certified Coder on the status and final resolution of a referral WebOPUS generates and stores all correspondence, letters, and agreements associated with a referral, easily accessible at anytime. IC_Solutions – How To Refer, Manage, Save

Independent Medical Evaluation & Physician Review Services

Medical Evaluation Services Multi-disciplinary network of Board-Certified physicians Providers that maintain an active treating practice with no restrictions Medical Evaluation referrals via the internet Timely appointments and subsequent appointment management Timely receipt of initial and final Medical Evaluation reports Thorough quality assurance program to ensure client specific parameters are being met Centralized management of referral from start to finish is accomplished via WebOPUS WebOPUS Browser available to access real time information, reports, and communications

Independent Peer Review 25+ years 45,000+ reviews performed in 2009 National Panel of Reviewers URAC IRO accredited All lines of business and levels of review TAT to meet your business needs Dedicated customer service teams HIPAA compliant technology SAS 70 Type II certified Web referrals

National Reviewer Panel Over 1,100 reviewers All ABMS specialties and subspecialties Board-certified Active clinical practice Current, unrestricted state license(s) Well established credentialing committee Oversight by MCMC’s Medical Director Re-credentialed every three years Verification of key credentials Independent Peer Review

Medicare Set Aside Services Experienced nurses certified in life care planning available to review medical records for : Compensable body parts/conditions Potential for rated age Appropriateness of past treatment/medication use based on clinical practice guidelines and/or ODG Compliance with treatment, response to past treatment and recommendations for future treatment Pharmacy Benefit Reviews Rated age vs. chronological age determines life expectancy on which future costs are based Partner with leading law firm to provide legal opinion letter, handle interface with CMS, provide legal support Ten Day Turnaround Time

Fraud Abatement & Record Retrieval Services

Fraud Abatement Services National service capability Services: Mobile and Stationary Surveillance Covert surveillance Activity checks/neighborhood canvass Wellness checks Robust quality assurance program All referrals and reports/video delivered via the web DIGG-IT Unique service Internet based investigation focusing on the top social networking sites such as Facebook, Myspace, Orkut, Youtube, LinkedIn Civil and Criminal History E-Commerce sites such as EBay and Craigslist Deep Web Research into the interests, lifestyles, and activities of your claimants

Record Retrieval Services National service capability Service offering: Authorization Procurement Subpoena Preparation and Service Expedited Service Index Hospital Records Provider Research Copy Records X-Ray Duplication Record Pick up Cost-effective solution to attorney charges All services delivered through paralegals and experienced record retrieval staff High sense of urgency and industry leading turnaround time

Proprietary Technology – WebOPUS Case Management Portal

Overview of WebOPUS - Robust case management system designed for the proactive case manager that creates bottom line results in today’s competitive industry Enables case managers to focus on their patients and provide the most effective oversight by automating their day-to-day tasks Structured to integrate all of the Managed Care Services and Activities involved in the continuum of claims management An Information Management Tool used to consolidate and coordinate healthcare and claims management activities Comprehensive Data Collection and Tracking application Flexible rule base logic to provide situation alerts and create triggers to facilitate prompt and effective decision making Portal that weaves the data points from all case management activities into one single comprehensive point of entry

WebOPUS Capabilities - Roles Supported Case Manager & Coordinator Utilization Review Nurse & Coordinator Call Center Care Coordinator Review Physician Vocational Rehabilitation Specialist IME Coordinator Claims Adjuster Online Approval Adjuster Invoice Coordinator Nurse Bill Review Auditor Network Manager Worksite Coordinator Support Management

WebOPUS Capabilities - Modules Supported First Report of Injury/Illness/Absence/Accident/Disability Module Ability to create new claims for workers’ compensation, auto liability, and general liability Service Referral Module Ability to create a referral, typically for IME, Peer Review, Desk Audit etc. Production Module - Manage Your Worklist Primary module. Supports all the various production roles and client and/or industry specific business logic Browser Module Allows for real time review of cases, documents, notes, treatment plan, return-to-work etc. Comprehensive Reporting Module Provides for over 25 canned reports available from the Web, ranging from Open Case with Current Lost Time to Timesheet Management Reports.

WebOPUS Capabilities - Core Section Overview Activities Section Search and Attach Treating Medical Provider on a claim Ability to create Loss Descriptors with ICD-9 codes automatically linked Create comprehensive Clinical Treatment & Management Tool Notes Section Correspondence Ability to view, email, and/or fax all of the Documents Received & Created Ability to create Standardized and Personal Letter Template Documents Claimant Summary overview of the demographic and past medical history linked to a claimant Treatment Plan Summary overview on the Treatment Plan Management and Disability Duration Billing Ability to view all the Historical and/or Pending bills associated with a claim including EOR, Medical Image and Payment information Utilization Review Ability to complete a Utilization Review/Pre Cert on all States, including State required Letters & Correspondence

WebOPUS - Browser Tool Facilitates communication with real-time access to user friendly, web-based care management software Provides browsers the ability to: Follow the medical & disability aspects of cases online Review disability guidelines by diagnosis code Communicate with nurse case manager online Locate medical providers by location/specialty Receive auto email alerts of new First Reports of Injuries & Case Management Episodes of Care Retrieve Case Management Reports online Review the medical payment history on a claim Retrieve & Review medical documents attached to a claim Generate Management Reports on demand

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