An Integrated Approach to Delivering Benefits to Your Customers

Both you and your employer customers continuously look for ways to deliver an attractive benefits package to employees in an efficient, coordinated, cost-effective manner. The more benefits that are included, the more complex administration becomes for all of the key stakeholders.   Employees often fail to maximize their benefits during the plan year due to confusion.  Employee satisfaction could be increased by streamlining interaction with their healthcare provider at the point of care, eliminating any additional steps required for employees to access benefits, while at the same time minimizing administrative costs for their employer and the payor.

Enhancing the Experience for Limited Benefit and Mini Med Plan Members

Working in conjunction with some of the leading Limited Benefit, Mini Med and Discount Card companies TriHealix, Inc. has developed an eligibility and payment portal to streamline communications between employees and their healthcare providers and accelerate payment.  The comprehensive web based application allows providers to determine their patients' financial liability at the point of care.   Further, providers may elect to receive payment directly via Electronic Funds Transfer (EFT) as an additional incentive to utilize the portal.   Clearly, most providers are eager to receive payment in a timelier manner and payors would prefer a lower cost alternative to paper checks.

Applying this technology to the Limited Benefit or Mini Med market allows payors to better meet the needs of the provider community by allowing them to access benefit information to determine the amount the patient owes while the patient is still in their office.  The cost as well as the complexity of patient billing and collections is burdensome with success rates of collecting the post insurance balance often low.  According to a recent McKinsey study¹, physicians and hospitals typically collect only about 50 percent of the post insurance balance – and only 10 to 20 percent for self-pay patients. The ability to verify eligibility and benefit information at the point of service not only improves operational efficiency, but also reduces administrative costs as well as reduces the need for balance billing to create a better experience for the provider. Employees also win – benefits are maximized at the point of care reducing out of pocket expenses for services covered by the plan and the question of "what is this going to cost me?" is answered.

So how can technology help an employee maximize their benefits and reduce out of pocket expenses? TriHealix has developed a platform that coordinates benefits and payments from multiple types of insurance, personal credit or checking accounts and wellness programs. On receipt of the claim, the TriHealix Multi-Authorization Processing (MAP) technology looks for all available sources of insurance and financial accounts for an individual to deliver a single payment to the provider that submitted the claim. Now, when the employee goes to the doctor, hospital or pharmacy, both primary insurance and supplemental insurance benefits are applied, followed by funds from available financial accounts to cover the employees out of pocket costs. The TriHealix MAP technology significantly reduces the complexity of administering multiple benefits, enabling brokers and agents marketing workplace benefit packages to offer a simplified experience for both the employer and their employees.

A hurdle to implementing these programs is the need for an immediate response from the claims adjudication engine.  Some payors have legacy systems that are not able to generate the adjudication response in real-time (seconds – not minutes, hours or days). Through a partnership with Hammerman & Gainer, Inc. (H&G), TriHealix and H&G have developed an end-to-end solution for workplace benefits distribution that creates improved operating efficiencies and streamlines benefits administration.  "Partnering with TriHealix increases satisfaction for all the participants in the program while reducing operating expenses for our payor clients," said Jimmy Hersman, Vice President of Consumer HealthCare Services with Hammerman & Gainer. H&G spent the past year developing a claims adjudication engine designed specifically for the Limited Benefit Plan market. 
The H &G engine features a user definable rules engine that drives all adjudication, workflow and CRM functions providing real-time substantiation of healthcare claims.  Providers access the system through a custom portal that allows for the submission of claims.  The provider may still submit batch electronic or paper claims for their patients.  The paper claims will be converted into electronic transactions through the portal and payment will be made back to the provider either via Electronic Funds Transfer (or a paper check if necessary). 

Discount Card Program Applications

As consumers become more savvy shoppers, utilizing the Internet as a tool to determine the value of the discount compared to the monthly or annual costs, there continues to be downward pricing pressure on the market.  Additionally, the provider community continues to be challenged with identifying the discounts associated with these programs and collecting the patient payment after the appropriate discount has been applied.

TriHealix, working with some of the largest providers of medical, pharmacy, dental and vision services discounts, has developed a revolutionary business model that allows individuals to enroll in discount programs at no charge.  Rather, the discount plan members pay an access fee (a small percentage of the savings) when they utilize the discount network.

Payment of the access fee at the point of service is facilitated either by a line of credit or other personal financial account as provided by the member during enrollment in the program. Providers participating in the discount program submit claims through the portal which are discounted in real-time enabling the provider to determine the amount the patient owes at the point of service. Using the TriHealix MAP technology, TriHealix initiates the financial authorization request for funds against the account(s) on file for the member. Patient funds are sent to the provider via EFT in the following 2-3 days.

So how does this program benefit brokers and agents delivering workplace benefits? The TriHealix Discount Access Fee Model allows the broker or agent to expand the offering of these programs and provides an incentive payment each time the member accesses the program.   Unlike other programs, where the agent may be penalized due to utilization or perceived overutilization of the program, this fee for service model rewards the agent that properly educates members and drives utilization.

TriHealix Background

TriHealix was founded to solve for the growing consumer liability, either at point of care or through interfaces with payors. The TriHealix integrated healthcare and financial transaction platform, designed to administer today's complex health insurance products, streamlines the settlement process between payors, providers and consumers. The TriHealix Platform enables simultaneous, electronic communication and data sharing by all parties to the healthcare transaction – from point of care, to consumers' insurance companies, to their financial institutions, and back. TriHealix provides easy to use tools and point of sale systems to connect healthcare providers to its platform, enabling single, consolidated payments from both payor and consumer. Not only will providers have access to multiple sources of funds for payment, they will also receive an integrated statement for quick and easy reconciliation. Payors partnering with TriHealix to connect providers to the platform can derive new revenue streams and ultimately reduce claims adjudication costs. By issuing a TriHealix integrated health ID and payment card, payors can improve the consumer's experience at the point of care, helping them to maximize benefits and reduce out of pocket expenses. Consumers receive a single, understandable statement of activity for all health related transactions. 

For more information about TriHealix visit www.trihealix.com. You can also hear Mark Keck speak on the subject of Integrated Solution Platforms that Coordinate Benefits and Payments at the Workplace Benefits Mania 2008 taking place July 28-30 at Caesars Palace, Las Vegas, Nevada.

Mark Keck - Executive Vice President TriHealix

Mark Keck has been engaged in a range of healthcare product development endeavors as well as frequent public speaking and writing. His 16-year career within the healthcare and finance industries includes experience in sales and business development, strategic planning and product development. Prior to joining TriHealix, Mark was Vice President of Healthcare Solutions for American Express where he developed healthcare strategy and positioning for the company. Mark designed and led the implementation of market leading Consumer Directed Healthcare solutions through partnerships with four of the top five national health plans. Prior to American Express, Mark served as Executive Vice President of the New York and Tampa markets for Motivano, a human capital management company providing nontraditional benefits through customized web portals and healthcare debit cards. While at Motivano, Mark led the strategy and development of their SmartAwards™ and SmartFlex™ products. Before Motivano, Mark spent several years at Oxford Health Plans as Regional Manager in New York, where he managed sales, marketing and product development for several regions. He has also held management and sales positions for Prudential Insurance Company and U.S. Healthcare. Mark holds a bachelor's degree in Policy Management Studies from Dickinson College.