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<br />3, <br />¡m <br />::II <br />::!I <br />::!I <br />;! <br />3 <br />:I <br />3 <br />3 <br />:I <br />:1 <br />3 <br />:I <br />J <br />J <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />1 <br />1 <br />I <br />I <br /> <br />"..., . <br /> <br />_:, ,!.v" . .--.. '. '"':. ' <br /> <br />,. " <br /> <br />Consulting Action Plan Steps 1 - 7 <br /> <br />Step 2- Revie\v and Analyze (cont.) <br /> <br />ê~ <br /> <br />Utilization review and Large Claim Management procedures <br />;.:\ In house or outsourced <br />.:~ Number of nurses on staff and their qualifications <br />;-'" Maternity specialist on staff <br />~"J. Hourly rate and billing increments <br />;~ Review criteria <br />.:,l Integration with claims payment, customer service and eligibility <br />¿.;\ Cost containment <br />Re-pricing claims completed in-house or sent to PPO <br />Procedure for handling hidden provider claims <br />Claims processors <br />;-.1 Years of experience <br />;'." Claim limit authority <br />;- ~ Designated claims contact <br />Internal communication between departments (ClaimsIUR/LCM/FMLA notification) <br />Disease Management programs <br />Centers of Excellence <br />Medical personnel on staff <br />Audit Procedures <br />; ;¡. Standard procedures <br />;!. Dollar triggers <br />;~ Percentage of large claims audited <br />< ,\ Coding accuracy <br />;.j}. Procedure for identifying bundled charges <br /> <br />;. ,(\ <br /> <br />; .\ <br /> <br />i~ <br /> <br />;' J. <br /> <br />;. <br /> <br />~. .t <br /> <br />il. <br /> <br />,;~ <br /> <br />PPO contracts to include, <br />< ,." Geo-access reports <br />; ~ Fees <br />~'3. Average discounts <br />;~ Utilization <br />;'.:L Re-pricing procedures <br />¡.;. PPO wraps for non-network claims <br />(;\ Prepare summary of current employee provider usage <br />~ ~ Prepare Betwork evaluation based on utilization data and available networks <br /> <br />.. <br /> <br />. , "P¡'escription Benefit Manager (PBM) contracts to include, <br /> <br />. ~.. . '...., <br />~1 Cost analysis <br />i.. Discount analysis <br />.'~ Dispensing fee analysis <br />il Drugs on Formulary and Non-Formulary Lists <br />it. Rebate analysis <br />a Mail order utilization benchmarks <br />'~ Detennine costs savings of implementing a direct PBM contract <br /> <br />CRIZZAFFI DARBY <br /> <br />GI) <br /> <br />Btll~/jt D.,i/C" "lid .\[all"/ltllten' <br /> <br />~,;¡-,'~iH~~~.::' .:.;1;;'¡~"",-:"(_~7~ =~~""'i>. ,.,~ :V"~:~4!,.:r'."'¡¡O~~..~..~ ~."""'-"""~J~"~6~.",l!:!r.o,? .æ'~¡'~:"'k£. """""~---"""'ZJIm."" ;:""""';;; ¡ <br />