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Care advocates evolent health presentation
- 1. by gilsbar, inc. by gilsbar, inc. Evolent Health Presentation Derrek Barfield, Senior Sales Executive Doug Layman, EVP, CSMO
- 2. by gilsbar, inc. Our Vision. Our personal healthcare experts engage members and guide them through the complex healthcare system, creating savings in both time and money.
- 3. by gilsbar, inc. Evolent Health The words evolve and transcendent define our ambition and inspire our name. We aim to help our partners evolve their approaches to care delivery and reimbursement beyond the current model, and in so doing, achieve transcendent outcomes for their organization and the populations they serve.
- 4. by gilsbar, inc. Strategic & Cultural Alignment Care Evolent Advocates Health
- 5. by gilsbar, inc. Gilsbar differentiators • A health and benefits organization for over 50 years • Skilled in healthcare, vision, dental, life and disability plan management and customer service as a third party administrator • Own our medical management company that has provided patient care management for over 20 years • Registered nurses and benefits professionals triage incoming calls and service • Consistently ranked among the ―best of the best‖ in customer and employee satisfaction • Healthcare clients represent a significant percentage of Gilsbar clientele
- 6. by gilsbar, inc. Patients are relatively inconsequential in healthcare today. How can we put them at the forefront and give them the resources they need?
- 7. by gilsbar, inc. The need for advocacy. INSURANCE IS CONFUSING. • Filled with jargon and acronyms that only those in healthcare or benefits understand • Loop holes in the system make it hard to navigate • Access to care is becoming more complex and restrictive
- 8. by gilsbar, inc. The need for advocacy. HEALTHCARE REFORM • FSA caps and more out of pocket for employees • Exchanges may force employees out of employer health plans • More patients in the healthcare system leads to shortages in providers • Rampant confusion in the marketplace
- 9. by gilsbar, inc. The need for advocacy. AGING POPULATION • One in four American adults provides care for an aging parent1 • Complexities in Medicare, parts A, B, C, D, supplements and Rx •Long term care needs prompt many questions in coverage, facility options, in-home care 1Atlanta Journal-Constitution writes in Caring for Parents Increasingly Costly that ―One in four American adults provides care for an aging parent, a threefold increase since 1994.
- 10. by gilsbar, inc. The need for advocacy. HEALTH EDUCATION & RESOURCES • Endless information available on the web ~ causes confusion and stress. • Who do employees turn to for education on a new diagnosis or condition? • Where will they find the highest quality providers and facilities? • Who can they trust to help them navigate the system, understand the costs, and make the best choices?
- 11. by gilsbar, inc. The need for advocacy. PRESENTEEISM & PRODUCTIVITY • Costs of presenteeism are estimated at $2,000 per employee per year • Employees are working through difficult personal healthcare issues for themselves, and their family members, on work time, contributing to lost productivity. • The stress and distraction involved is a direct cause of presenteeism during working hours.
- 12. by gilsbar, inc. Healthcare Who’s responsibility is it to Reform help employees? • The epicenter is typically HR or the Presenteeism & Productivity Insurance Confusion broker. HR/Benefits • Insurance call centers can help, but Broker don’t help with the whole maze. • Who is the best resources to help with PHI and referrals? • Who has the time to really devote to Health Education Aging Population employees’ personal needs and those of their family?
- 13. by gilsbar, inc. Care Advocates takes on the responsibility. Healthcare Healthcare Reform Reform Presenteeism Insurance Presenteeism Insurance & Productivity Confusion & Productivity Confusion HR/Benefits Care Broker Advocates Health Aging Health Aging Education Population Education Population
- 14. by gilsbar, inc. Comprehensive Service Bundle
- 15. by gilsbar, inc. Assists members with understanding benefits and what they cover. • Explanations of EOBs, co-payments, deductibles and out-of-pocket expenses • Explanations of coverage including dental, vision, life, disability and more • In-network vs. Out-of-network providers and how to best use benefits • Assistance locating in-network providers • Coordination of benefits between multiple carriers • Pros and Cons of FSAs, HRAs and HSAs & help making the right choices
- 16. by gilsbar, inc. Provides expert assistance with claims, EOB’s and billing. • Answering questions about paid or denied claims • Explaining the details of the medical claims payment process • Explaining EOBs and what out-of-pocket responsibilities specific claims may represent • Resolving claim and billing issues • Assisting with pre-authorizations • Assisting with claims appeals • Facilitating coordination of benefit filing • Facilitating discussions with non-network providers on reasonable and customary charges
- 17. by gilsbar, inc. Offers assistance with coordination of care. • Assistance finding a doctor, hospital or community resource • Help scheduling appointments with primary care physicians and specialists • Assistance with referrals, pre-authorization and second opinions • Assistance transferring medical records, including x-rays and test results transfers between hospitals or other medical service providers • Explanations of test results after a doctor visit or after an employer’s wellness health fair • Clarifications regarding recent diagnoses—what they mean and what treatment options are available. • Clarifications regarding recommended treatments, explained in simple and straightforward terms • Coordination of home health care visits and equipment • Explanations of what to expect before and after a surgery, procedure or diagnosis • Coaching on lifestyle changes to improve health
- 18. by gilsbar, inc. Provides care coordination for aging parents. • Making arrangements for visiting nurses or personal care providers, hospice, home health or equipment • Assistance finding a doctor, hospital or community resource • Help scheduling appointments with primary care physicians and specialists • Assistance with referrals and pre-authorization • Assistance transferring medical records, including x-rays and test results • Explanations of test results after a doctor visit or after an employer’s wellness health fair • Clarifications regarding recent diagnoses—what they mean and what treatment options are available • Clarifications regarding recommended treatments, explained in simple and straightforward terms • Help obtaining a second opinion if requested • Coordination of transfers between hospitals or other medical service providers This service is provided to the elderly parent and coordinated through their named dependent.
- 19. by gilsbar, inc. Standalone Products
- 20. by gilsbar, inc. Provides assistance during annual open enrollment to improve employee engagement: • Provides dedicated telephone support during the annual enrollment period • Help members understand all the benefit options available • Help members model their choices from a financial and coverage perspective • Explain consumer directed healthcare options and provide tools to help members understand choices available to them
- 21. by gilsbar, inc. Provides expert assistance to help members save time and money in the following areas: Negotiation of Uncovered or Out-of-Pocket Medical Bills – Our billing specialists can help negotiate down the cost of out-of-pocket medical bills, thereby gaining a discount for services rendered. Out-of- pocket claim expenses are negotiated at a reduced rate to help members manage overall costs. Medical Billing Audits/Reviews – Our advocates will review and audit medical bills for errors, including overcharges, unbundling, duplicate charges, incorrect diagnoses, ―billed-but-undocumented‖ and other areas related to generating a correction.
- 22. by gilsbar, inc. What are the benefits? Employees + HR / Employer = Healthier Business Broker / Consultant • Less stress • Less burden on HR • Solidifies your • Reduced expenses • More time to focus on relationship with • Higher benefit strategic initiatives client satisfaction • No PHI/HIPAA concerns • Drives your value- • Consolidated resource • Increased productivity added suite of for all benefits, even • Decreased services non-employer presenteeism • Provides a sponsored unique, • Consolidated resource unanticipated for entire family, even if solution not covered on employer’s plan
- 23. by gilsbar, inc. Member communications that are engaging, attractive and compelling drive awareness of this valuable new benefit. • Wallet cards • Welcome brochures • Quarterly E-newsletters • Posters • Table tents with tear off cards • Key fobs • Magnets
- 24. by gilsbar, inc. Step 1: Sign How do I get started? Contract EASY Step 4: We Step 2: Send start taking eligibility file calls! We also offer: • A dedicated account management team • Quarterly reporting on number Step 3: Provide and nature of calls, group benefit engagement and touch points documents
- 25. by gilsbar, inc. Thank you! by gilsbar, inc. We look forward to hearing from you! Care Advocates by Gilsbar, Inc. 2100 Covington Centre Covington, LA 70433 1-800-445-7227 Extension 830
Hinweis der Redaktion
- Good morning, everyone. I am excited to share with you today a facet of healthcare that tends to get overlooked, which is: how do we, the consumers, come to a greater level of understanding and engagement in our own healthcare and in the healthcare of those we love, especially in light of the complexities and constant changes in the healthcare system?To start off, I am going to ask a few questions, and I fully expect audience participation. These are not rhetorical questions.Over the past 12 months, has anyone spent time researching a health condition, with on the internet or otherwise?Over past 2 years, anyone spent time trying to understand a health insurance claim or benefit and had to reach out to someone for clarification?Do you know anyone who has had to spend time trying to figure out options and details surrounding care for parents or elder care?
- How do we do this? Giving a third party to help people understand their benefits and claims, and even helping them file claims appeals Experts support decision making for Medicare issues and long term care considerationsClinicians assist in care coordinationOur differentiators:• We have complete coverage and excel in both the benefits/claims side and the clinical side. All others are more heavily focused in one area and “sort of do” the other.• We've been answering benefit and claims questions (health, dental, vision, life, DI) for self-funded and fully insured plan members all over the U.S. for 53 years. We've been doing the same on the clinical side for 21 years. This is not new to us and • As a Health & Benefit Management Company, who administers self-funded, fully insured and association plans across the county, we have access to and are able to utilize data sets, PPO contract details, PBM formulary details, etc. to more efficiently help people.• We own our own PPO, we know how hospitals work, how they think, how they bill and why.• We pay medical claims for more than 100,000 plan members – we know how to advocate and challenge companies like us and carriers.• On the clinical side, we are staffed with RNs (vs. aides) and we have RNs who specialize in Cardiac Care, Diabetes, Neurology, Neonatology, Maternal-Child, Oncology, Orthopedics, Psychology – Behavioral Health, Rehabilitation and Transplant.• ParentCare is a differentiator…Health Advocate lists it as a service, but I haven't found anyone who actually used it. Our ParentCare is also supported by RNs who specialize in Medicare.• We excel at out of pocket negotiations (something that most of the other don’t do)– we’ve been doing it for 35 years and our results meet or exceed the market specialists.• Advocate is only good if people use it. We’ve been doing wellness plans for clients since 1986. A critical factor in a successful wellness plan is if people use it…in order to use you have to market and engage the employees. We’ve borrow this approach and process for our promotion of Advocate.
- How do we do this? Giving a third party to help people understand their benefits and claims, and even helping them file claims appeals Experts support decision making for Medicare issues and long term care considerationsClinicians assist in care coordinationOur differentiators:• We have complete coverage and excel in both the benefits/claims side and the clinical side. All others are more heavily focused in one area and “sort of do” the other.• We've been answering benefit and claims questions (health, dental, vision, life, DI) for self-funded and fully insured plan members all over the U.S. for 53 years. We've been doing the same on the clinical side for 21 years. This is not new to us and • As a Health & Benefit Management Company, who administers self-funded, fully insured and association plans across the county, we have access to and are able to utilize data sets, PPO contract details, PBM formulary details, etc. to more efficiently help people.• We own our own PPO, we know how hospitals work, how they think, how they bill and why.• We pay medical claims for more than 100,000 plan members – we know how to advocate and challenge companies like us and carriers.• On the clinical side, we are staffed with RNs (vs. aides) and we have RNs who specialize in Cardiac Care, Diabetes, Neurology, Neonatology, Maternal-Child, Oncology, Orthopedics, Psychology – Behavioral Health, Rehabilitation and Transplant.• ParentCare is a differentiator…Health Advocate lists it as a service, but I haven't found anyone who actually used it. Our ParentCare is also supported by RNs who specialize in Medicare.• We excel at out of pocket negotiations (something that most of the other don’t do)– we’ve been doing it for 35 years and our results meet or exceed the market specialists.• Advocate is only good if people use it. We’ve been doing wellness plans for clients since 1986. A critical factor in a successful wellness plan is if people use it…in order to use you have to market and engage the employees. We’ve borrow this approach and process for our promotion of Advocate.
- How do we do this? Giving a third party to help people understand their benefits and claims, and even helping them file claims appeals Experts support decision making for Medicare issues and long term care considerationsClinicians assist in care coordinationOur differentiators:• We have complete coverage and excel in both the benefits/claims side and the clinical side. All others are more heavily focused in one area and “sort of do” the other.• We've been answering benefit and claims questions (health, dental, vision, life, DI) for self-funded and fully insured plan members all over the U.S. for 53 years. We've been doing the same on the clinical side for 21 years. This is not new to us and • As a Health & Benefit Management Company, who administers self-funded, fully insured and association plans across the county, we have access to and are able to utilize data sets, PPO contract details, PBM formulary details, etc. to more efficiently help people.• We own our own PPO, we know how hospitals work, how they think, how they bill and why.• We pay medical claims for more than 100,000 plan members – we know how to advocate and challenge companies like us and carriers.• On the clinical side, we are staffed with RNs (vs. aides) and we have RNs who specialize in Cardiac Care, Diabetes, Neurology, Neonatology, Maternal-Child, Oncology, Orthopedics, Psychology – Behavioral Health, Rehabilitation and Transplant.• ParentCare is a differentiator…Health Advocate lists it as a service, but I haven't found anyone who actually used it. Our ParentCare is also supported by RNs who specialize in Medicare.• We excel at out of pocket negotiations (something that most of the other don’t do)– we’ve been doing it for 35 years and our results meet or exceed the market specialists.• Advocate is only good if people use it. We’ve been doing wellness plans for clients since 1986. A critical factor in a successful wellness plan is if people use it…in order to use you have to market and engage the employees. We’ve borrow this approach and process for our promotion of Advocate.
- Health care does little to make health care more understandable. Is it coincidence that the word “patient” is almost inconsequential in PPACA legislation?Many of us have questions/issues, and we are in the healthcare industry!! If we have had struggles with this, imagine what the layperson goes through on a regular basis?So, what is causing the complexity confusion in understanding our healthcare system? I offer a few possibilities.
- Imagine your computer was broken and you brought it to me. I’d tell you: “Someone probably cracked your WEP or spoofed your NIC by cloning your MAC, make sure it using the SCSI to boot and not the SATA, and hope nothing corrupted your sector zero or FAT table. Do you know what’s the problem with your computer, or the solution, for that matter?
- Complications surrounding Medicare: Parts A, B, C, D. Plans A, B, C, D, F, G, K, L, MLong Term Care needsAtlanta Journal-Constitution writes in Caring for Parents Increasingly Costly that “One in four American adults provides care for an aging parent, a threefold increase since 1994So, is this a problem?As this demographic grows over the next 20 years at the rate of 10,000 per day, so are the complexities and confusion surrounding Medicare and long term care needs. This is not just a problem for the baby boomers, but for their children, as well.
- Sitting in front of the TV, it seems like everyone has clogged arteries, a sleep disorder, and erectile dysfunction, and only these drugs can help me.The media has a tremendous influence on health care decision making.If you have been diagnosed with a disease or a condition, do you need a specialist? A second opinion? A center of excellence?If you are being treated by multiple providers, who helps with the coordination of information between all of them?Are you following a formally recognized standard of care?From a consumer-driven standpoint, Which hospital has the best outcomes for certain procedures? What is the cost differential for certain procedures between facilities?Many times making a decision regarding one’s healthcare feels like a guessing game, both from a quality and a value standpoint
- Obviously, the overall complexity of our healthcare system takes its toll on both employees and employersFrom a macro perspective, there is an effect on the employer, the industry, and the entire economyFrom a micro perspective, the individual consumer takes it mentally and financially.Costs of presenteeism are estimated costs are $150 - $250 billion annually. http://www.businessknowhow.com/manage/presenteeism.htmThough there are many factors that contribute to this figure, a component piece is the individual’s health as well as a preoccupation for the wellbeing of family members, especially elderly family members.
- HR professionals, customer service reps from our insurance companies, brokers, and health care providers all do well at their respective jobs, but none of them manage the entire healthcare continuum. They may be able to guide us through a portion of the maze, but not the entire maze.And in reality, it’s still HR’s job to provide resources to employees to help understand benefits.
- HR professionals, customer service reps from our insurance companies, brokers, and health care providers all do well at their respective jobs, but none of them manage the entire healthcare continuum. They may be able to guide us through a portion of the maze, but not the entire maze.And in reality, it’s still HR’s job to provide resources to employees to help understand benefits.
- ELECTRONICA “Welcome Email” the group contact can send to employee/members with a wallet card “cut out” inside the email.(3) .jpg ads in various sizes the group and insert into their current communications vehicles, website, etc to promote Care Advocates to their membershipQuarterly email promotions sent to the group contact, which they can forward to their membership (this will happen automatically, each quarter. All clients will get the same quarterly promo email.) Employer groups will receive some or all of the following: PRINT HARD/COPYLarge Movie-Size PostersSmaller Posters with tear-off wallet cardsTri-fold brochures with tear-off wallet cardsPads of tear off wallet cards to keep in HRTable tentsMagnetsKey Fobs