November 24, 2011

Government of Bermuda

Health Insurance Department

Automation and Modernization Project

The Apollo Group: Healthcare Pedigree

• One of the largest global healthcare services organizations

• 25 years of experience, strong brand and commitment to quality healthcare

• Apollo is a family of 64,000 healthcare professionals

Largest TPA network

managing nearly 10

10 nursing, 3 hospital

management, physiotherapy

Owned /

Managed

Hospitals

Health

Education

& e-Learning

Clinical

Research

Retail

Pharmacies

Third Party

Administration

Health

Insurance

Apollo Health

Street

Primary Care

Clinics

Over 50 centers

focused on ambulatory

care and wellness

India’s most

innovative, pure-play

health insurance

company

managing nearly 10

million lives

management, physiotherapy

and much more

Over 1,200 centers

across the country

Focus on Phase 3 &

Phase 4 trials:

Working with leading

pharmaceutical

companies

4th largest global hospital. 45

hospitals with 9300 beds

ACHIEVING HEALTHCARE’S TRUE RETURN

Global Platform and Capabilities

• Global delivery centers provide significant advantages with seamless operations

• Provides for intra and inter city redundancies in global operations

Bloomfield, NJ

� Charity Care and

Eligibility

� FBO and EBO Services

� Self-Pay Collections

Conshohocken, PA � Third-Party Large Claims Follow Up

� Self-Pay Collections� Denial Management

Delhi, India

� Software Development and Upgrades

� Technical Support and Help Desk Services

New York, NY

� Account Management

� IT/IS Support

Los Angeles, CA

� Medi-Cal / Medicare Billing

� Medi-Cal / Medicare

Collections

� On-Site FBO Process for

Client

Sunrise, FL

� Bad-Debt Collections

� EMS Carrier Follow Up

� Client Relations &

Appeals

Americus, GA

� Mail Room / Scanning

� Claims Re-Pricing & Adjudication

� Help Desk / Customer Support

� Provider Calls

Hyderabad, India (2 Offices)� Eligibility� Coding� Billing / Credit Payment & Posting

� Third-Party Follow Up� Data Entry� Claims Re-Pricing & Adjudication

� Software Development

� Implementation

� Training

� Interfaces

Springfield, IL

� Medicaid Application

Services/Eligibility

Chennai, India� Opened facility in Aug. 2008

� Physician Revenue Cycle� Payer Data Management

Boston, MA� Third-Party Large Claims Follow Up

� Self-Pay Collections� Denial Management

Government of Bermuda

3

Technology

• An AS400 application supported policy administration and billing for one

customer segment only

• All the other work including claims adjudication was processed using paper

and excel spreadsheets

Bermuda Health Insurance Department

Challenges Prior to Automation

and excel spreadsheets

• Lack of confidence in the integrity of the eligibility, claims, and billing data

• Inability to capture and analyze data related to claims utilization, premium

and eligibility

Process

• Lack of properly documented policies and procedures

• Undocumented business rules resulted in inaccurate and inconsistent

application of claims adjudication

People

• With no automation, staffing levels were not sufficient to support the volume

of work resulting in backlogs and dissatisfied customers and providers

Technology

• Select and Implement a state-of-the-art Health Plan Administration System

• System to enable automation and integration of claims adjudication, premium

billing and enrollment

Bermuda Health Insurance Department

Automation Action Plan

• System to enable reporting for measurement of all operational and strategic

KPI’s – claims utilization, premiums, and enrollment

• System to enable electronic exchange of data between stakeholders –

hospital, physician, pharmacy, and finance

Process

• Documentation of all Business Rules, Policies, Procedures and Workflows to

ensure consistency and efficiency in all service areas

• Eliminate backlogs to improve customer service to members and providers

People

• Partnership with healthcare BPO to deliver back office transactional services

for non-customer facing functions

Bermuda Health Insurance Department

Global Partnership Solution

Implemented the technology solution and performs back office administrative functions – claims adjudication, enrollment processing, eligibility updates,

premium and standard

Retained customer service, finance, audit, marketing, and strategic

planning

premium and standard reporting

Provided the Health Plan Administration System (LuminX) through an ASP delivery model

Coordinated the development of policies and procedures working with Apollo Subject

Matter Experts and HID and provided other project management

support

• Selected state-of-the-art Benefit Administration Software based on analysis

of functional requirements detailed in government-issued RFP --- LuminX

System from Ebix.

• Chose ASP data model for increased data security, rigorous backup of data,

a robust disaster recovery / business continuity strategy, reduced capital

expenditures and reduced cost of hardware support and maintenance.

System Selection and Implementation

expenditures and reduced cost of hardware support and maintenance.

• Apollo professionals provided systems implementation, plan building and

training support

• Refined functional requirements during assessment phase. Produced gap

analysis and initial configuration and enhancement specifications.

• During implementation, developed cleansing and normalization strategy for

data, transformed and then migrated data from previous systems and other

external sources

LuminX Health Plan Administration System

Over 10 million covered lives

120 clients: TPAs, carriers, health plans, and others

ASP Delivery Model

• Configured claims adjudication parameters for automated processing based on

legislated benefit packages, adjudication rules and funding mechanisms

• Adjudication configuration increased productivity and accuracy of claims

processing

Automation of Claims Adjudication Logic

and Premium Billing

processing

• Integration with eligibility and billing data enables more accurate adjudication

based on premium status and eligibility dates

• Configured premium rate tables for individuals and employer groups for

automated billing

• Implemented acceptance of electronic pharmacy claims

• Implemented acceptance of electronic hospital claims (837 format)

• Implementation in progress for electronic explanation of benefits (835 format) to

Electronic Data Exchange with Key

Stakeholders

• Implementation in progress for electronic explanation of benefits (835 format) to

providers who are submitting electronic claims

• Implementation in progress for acceptance of medical claims (837 format) from

non-hospital providers

• Implemented electronic payments to providers

• Developed electronic eligibility updates to US provider network, dental

administrator, hospital

• Developed automated data extracts to print vendor for high volume printing and

mailing of billing statements and EOB’s

• Robust standard and ad-hoc operational reporting for claims,

premium, and enrollment

• Cognos data warehouse for executive-level decision support

and KPI tracking

• Standard and ad-hoc financial reporting

Reporting and Web Portal

• Standard and ad-hoc financial reporting

• Web portal for providers and policyholders to verify benefits

and check claim status

• Apollo’s Blended Shore Delivery Model allowed access to both US

and India-based resources for subject matter expertise in health

plan administration and operational management

• Cost-effective and high quality claims adjudication service from

Apollo increased accuracy and reduced turn-around-times

Leveraging New Technology and Back

Office Partner

Apollo increased accuracy and reduced turn-around-times

• Backlogs eliminated during implementation and ramp up

• Documented all existing manual workflows

• Mapped out future state workflows affected by business process

outsourcing and new technology

• Contributed best-practices and subject matter expertise to client’s

Documentation of Business Rules and

Workflows

• Contributed best-practices and subject matter expertise to client’s

development of new policies and procedures

• Strategic partnerships providing both the operating system and

professional support

• Apollo’s administrative support provided improved performance through a

cost effective multi-shore delivery model

• Bermuda was able to focus on measuring performance and overall

Business Strategy: Global Business

Partnerships

• Bermuda was able to focus on measuring performance and overall

delivery improvements while business partners handled volumes

• Partnership approach provided subject matter experts from Apollo and

EBIX along with project management support from IBM

• EBIX platform provided state-of-the-art capabilities in automation,

processing, and reporting

• ASP delivery model provided robust Disaster Recovery capabilities while

minimizing support costs

• Ability to leverage strategic partnerships provided flexibility in staffing

support for implementation, backlog reduction, and on-going support

Key Tactical Outcomes of Automation

Project

Reduced claim payment turnaround times and accuracy of claims

adjudication, improving relationships with providers, policyholders and other

stakeholders

Optimized back office operations resulting in more efficient use of existing

resourcesresources

Optimized electronic data exchange with key stakeholders improving

efficiency of Bermuda’s healthcare finance system

New processes and systems enabled capture of data previously unavailable

resulting in improved audit results and executive decision support

Reduced claim costs by standardizing processes and using the available

information to manage claims more effectively

Allowed HID staff to focus more on customer service and strategic

management of business