5/15/2017. What s New for 2017? Product/Network Chart. Continued Huge Growth! HealthEZ 35% - 40% growth each of the past 2 years

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1 Founded in 1982 by Nazie Eftekhari The original Preferred Provider Organization Product/Network Chart HealthEZ America s PPO Provider Products Direct commercial TPA business Partially self-funded group medical, dental and flex plans Business in all states nationally with emphasis on Midwest, West and Southwest and Southeast Custom benefit designs, innovative technology and concierge care 100% direct contracts with over 150 hospitals, and 71,000 physicians in MN, IA, ND, SD &WI Certified Workers Compensation Network in MN and SD Covers MN, ND, SD, part of IA and most of WI Clients include national networks, TPAs, and insurance companies EZ Pay available through HealthEZ TPA Pays patient liability directly to providers EZCare preferred reciprocal pricing available to HealthEZ provider clients Custom networks designed to facilitate on-campus care for hospital clients What s New for 2017? Continued Huge Growth! HealthEZ 35% - 40% growth each of the past 2 years America s PPO - continues to be the primary network for Mayo Clinic Health Solutions for MN and WI as well as many national networks (consolidation continues with national networks) Over 350,000 members through HealthEZ, national networks, insurance carriers and TPAs 1

2 Cost Plus Model - Health Reform HealthEZ administers partially self-funded plans we are not an insurance company nor do we have any government/exchange business In the chaotic world of ACA and now AHCA, self funding is the stable choice! Our business continues to expand nationally with growth in the West and Southwest, as well as the Southeast Model increasingly popular with smaller to mid-size employers with 5 Illness Health Complex Care Management Chronic Condition Management Advising Step One Foods Preventive Care Facilitation Challenges Seminars Activity Bands EZfit Vaccinations 6 2

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4 New Launch Custom Websites New Launch Custom Websites for providers A HealthEZ member presents a HealthEZ ID card with the statement: No Payment Due at the Time of Service HealthEZ collects from the patient what they owe you You receive payment in full from HealthEZ, patient and plan funds, in one check 4

5 Questions Received Billing & Management Codes HealthEZ allows a medical exam code when billed with a routine exam code IF the provider bills the modifier 25 on one of the CPT codes this tells us there was a separate procedure from the other exam. There can be conflicts with what members describe as the service rendered vs. the code billed when calling customer service. If preventive and billed with diagnostic code, we must pay accordingly. Appeals HealthEZ business - every appeal must be responded to in 30 days; most are handled within 2 weeks If we require more than 30 days, provider is notified of the delay Denials for lack of medical necessity need additional clinical information to support overturning the denial 5

6 Appeals Other denials are generally due to plan exclusions and those are upheld Code edit denials generally due to not billing the correct modifier. These are overturned upon receiving a corrected bill. Denials for no precertification these can be reviewed retrospectively and may be overturned. Customer Service Average wait time is under 30 seconds Company policy to return all calls within 4 business hours Each HealthEZ customer has a custom phone number; separate number for providers to call but they can call on the customer number too Provider calls for America s PPO business transferred to Provider Services Prior Authorization Required for the following: Inpatient admissions Outpatient surgeries Scans (need clinical to support MRIs vs. x-ray) Mental Health/Substance Abuse Treatment 6

7 TeleHealth HealthEZ clients have implemented Healthiest You as an option (acquired by TeleDoc) Integrated with our 24/7 nurseline if member could benefit from a prescription, they are warm transferred to Healthiest You Employers pay a capitated fee for the service Can integrate any telehealth services you are offering your patients Fully Integrated Claims submitted with ICD-9 code will be denied with a note to the provider to resubmit using an ICD-10 code Chronic Condition Management HealthEZ manages chronic conditions the same as complex conditions that are assigned a case manager. We often work with the patient and their family, identifying lifestyle and other issues that may impede compliance Nurses find the lowest cost for maintenance medication and can arrange for home delivery We allow for reimbursement when billed by NPs 7

8 Credentialing Process Criteria includes: Current valid license to practice Background of education and training Board certification Work history Current malpractice insurance We accept MN/SD/IA credentialing applications, universal credentialing application, as well as APPO custom application All providers must be approved by the APPO Credential Committee Organizational Structure Executives Provider Services Finance Amir Eftekhari President Tom Schmitt COO Jean LaFavor Vice President, Sales Josh Schreiner Provider Relations Matthew Parker Provider Relations Catherine Rogers Provider Support Specialist Josh Kutzler CFO Patrick Greenberg Analytics Associate Eric Lamote Vice President, Risk Provider Resources HealthEZ access benefits, eligibility and claim status online 24/7 - can now view complete SPD on employer custom websites Call Customer Service at America s PPO for non-healthez payers Provider Services team is ready to assist with any other questions or issues and will work with provider and payer to get issues resolved as quickly as possible 8

9 Thank You! Be sure to stop by our booth in the exhibit area and say hi! 9