Administration

The following services are performed on behalf of client organizations:

• Manage all administrative aspects of a health benefits program.
  
• Coordinate contracting, credentialing, utilization management, member services, provider relations, education, claims processing, billing and collection services.
  
• Maintain a liaison with insurers, employers, health plans and other payors in coordinating communications between members, ACA Administrators, Employee Health Systems and the Payor, and in resolving grievances between all parties.
  
• Develop and maintain all protocols, procedures and systems to administer health benefits programs
  
• Provide monthly reviews of utilization, payor contracts, and financial reports

Utilization Management

Being physician owned, our companies have established a utilization management program that employs an organization-wide, multi-disciplinary approach to balancing cost, quality, and risk concerns in the provision of patient care. The utilization management staff, working in partnership with our contracted physicians in the utilization review process, allows a close examination of all prospective, concurrent and retrospective procedures. If problem utilization patterns are identified, appropriate recommendations and actions can be taken by our physicians to address anomalies in utilization.

• Development and administer policies and procedures that meet regulatory compliance.
  
• Design and implementation of referral authorization, pre-certification, concurrent review, and case management process that meets the specific needs of payors and providers.
  
• Case Management and concurrent review done in partnership with contracted providers.
  
• Clear, concise guidelines for Primary Care Physician roles and responsibilities.
  
• Continuous education and training to physicians and staff regarding existing procedures, compliance issues, disease management and reporting guideline
  

Referral Process

UM Decision making is based only on appropriateness of care and service and an existing benefit of coverage. EHS does not specifically reward practioners or other individuals for issuing denials of coverage or service care. EHS does not provide financial incentives for UM decision makers and does not encourage decisions that result in under utilization.

Quality Management

Both ACA and EHS continuously monitor and evaluate the care and services provided by all contracted providers. The companies seek participation from and development with physicians, hospitals, ancillary providers and payers to improve the quality of clinical care to members.

• Participation in audits conducted by Payors or other outside studies.
  
• Educate and update physicians and providers on quality management trends, goals, and areas requiring improvement.
  
• Update physicians and providers on Payor requirements.
  
• Education physicians and providers on implementation of corrective action plans and reporting responsibilities.

Credentialing

Utilizing standards established by organizations such as the National Committee on Quality Assurance (NCQA), we actively credential all participating physicians and providers in its contracted networks. The credentialing program establishes rigorous and consistently applied standards in order to assure that only well-qualified and documented providers are eligible to participate. All specialists are board certified or eligible in their specific discipline in order to treat patients.

• Application for Membership.
  
• Physician CV, current licenses and certifications, professional liability insurance.
  
• Professional liability claims history for past 5 years.
  
• Hospital privileges status and disciplinary actions taken (if any).
  
• Queries to the National Practitioner Data Bank (NPDB), Federation of State Medical Boards, ABMS Directory of Medical Specialists (for Board Certified Physicians), AMA Database, local state medical boards, MBC Hot Sheets & Monthly Disciplinary Summaries, HHS Medicare & Medicaid Sanctions and Reinstatement Reports.
  
• Provider office site visits.
  
• Verification of Education and Training History.
  
• Board of Medical Examiners Check Results

Claims Processing

Claims staff are focused on identifying and recovering lost money on insured services, reinsurance, over-payments, third-party liability, coordination of benefits and retroactive terminations to insure proper reimbursement and collections. Our claims department currently processes over twenty five thousand (25,000) claims each month, providing efficient claims processing services with prompt courteous customer service with the goal of resolving outstanding claims issues quickly.

Finance & Accounting

For all clients, we develop, maintain and present accrual-based financial statements, including Income Statements and Balance Sheets in accordance with Generally Accepted Accounting Principles (GAAP) for those activities under contract. Thus, on any given month, we have an accurate picture of the earned income and accrued expense for the period, and a snapshot of the reserves required for payment of outstanding Incurred But Not Recorded (IBNR) claims and liabilities.

• Establish and supervise bookkeeping, accounting systems and records pertaining to manage care in accordance with GAAP.
  
• Establish projections for managed care business, which reflects major operating objectives and anticipated revenues, expenses and cash flows.
  
• Establish and maintain an accounts payable system.
  
• Generate and distribute reports as required.
  
• Establish a statistical information gathering system as required.
  
• Administer claim processing systems with appropriate reviews and controls.
  
• Administer a capitation distribution system.
  
• Maintain appropriate IBNR (incurred but not reported) accounts based on lag analyses.
  
• Administer incentive programs.

Information Systems

Our state-of-the-art infrastructure and technology integrates and automates all administrative, managed care, financial and clinical functions essential for operating healthcare delivery networks. Our hardware platform is a Compaq Proline 6500, with Windows NT and Microsoft SQL Server 2000. Our application software is HealthTrio Xpress. Our systems are extremely flexible and scalable, meaning as the needs of the business grows, so does the software to handle it. We can manage an unlimited number of payor types, including HMO, PPO, point-of-service plans (POS), Medicare, Medicaid, and self-funded employer and ERISA trust health benefit plans. ASP Services are also available

Enrollment (Eligibility/Verification)

Our enrollment eligibility department tracks and maintains eligibility information for every member covered under a health plan contract. We understand the importance of providing our healthcare providers and members with fast, responsive service regarding enrollment and eligibility. We diligently work to provide our providers and members with a 24-hour response time while servicing their enrollment needs.

Provider Relations / Member Services

We believe there are two types of members - Physicians and Patients. We place a high priority in providing superior customer service for both groups. We are committed to providing proactive, efficient solutions to ensure that delivery of appropriate health care and effective medical management continues without interruption. Questions, complaints, concerns and grievances are handled and tracked, with detailed data collected and provided through our Quality Management committee structure for follow-up and resolution, including all data requirements of payors and regulatory entities.

Network Development

Both ACA and EHS have many years of experience in the development and management of fully integrated healthcare networks. We have successfully worked with labor unions in the establish-ment and management of Taft-Hartley ERISA trust fund networks in many states. As a result, we are in a unique position of creating networks of physicians and hospitals upon which we can "piggyback" other products and services. Our network reaches 12 states and encompasses over 15,000 physicians.

Contracting

Company staff come from a variety of backgrounds, including hospitals, medical groups, IPAs and health plans, which provides the negotiating and purchasing expertise required by payors. We pursue, negotiate and manage contract agreements for every type of relationship that is essential to the operation of an integrated healthcare delivery system.