The UMR
Advantage
A unique solution for
the self-funded market
The value and advantage of UMR
We are the only TPA that:
•
Offers the significant network discounts and infrastructure investment
of a Fortune 50 company
•
Offers fully integrated internal benefits solutions, such as care management,
pharmacy benefits administration and stop loss; or can plug and play with
your preferred vendors
•
Can quickly respond to state and federal mandates, regulators and market
changes
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Most of all, we know how to put Customers First.
We call it the UMR advantage.
We offer hospital-specific solutions based on:
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Sophisticated plan designs that promote domestic utilization, driving clinical
care and revenue to your providers and facilities
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Integrated products and services that incorporate your clinical resources and
organizational culture to deliver cost savings
•
Market experts dedicated to serving the needs of hospital and health care
systems and specialized customer service teams trained on the intricacies of
hospital benefits administration and organizational culture
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What you should know about us
We’re big. But we’re also local and regional in scope with claim offices in each time
zone and account management staff in just about every state, close to our customers.
We have more than 3,000 people who can focus their expertise and experience on
your plan.
We serve more than 1,400 customers and their more than 2 million members every
day – accurately, carefully and compassionately. Our customers range from mid-sized,
self-funded companies to coalitions of employers to large state governments.
You should know, we treat each one with the same amount of care and expertise.
Most of our customers ask us to administer multiple, unique plan designs with various
reimbursement methods …
It’s what we do best.
With more than 100 account management staff, it’s likely yours will be in driving
distance of your office.
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Dedicated to serving hospitals
UMR administers self-funded benefit plans for hospitals and health care systems coast
to coast, serving more than 460,000 hospital plan members. Our health care clients
range from rural, stand-alone hospitals to multiple-facility integrated delivery systems
with complex organizational structures.
We have a team of product experts dedicated to serving the hospital market to ensure
we are doing everything we can to meet your needs. These market experts can provide
you with a variety of networking and educational opportunities to help you make
strategic decisions about your benefit plans.
In 2011, our book-of-business trend for hospitals was 2.8 percent per employee per
year on a paid basis.
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UMR hospital summit
As a UMR hospital client, you will be invited to our annual
hospital summit, a two-day event that brings our hospital customers together
to exchange ideas with peers from across the country. The UMR hospital summit offers
an informal, yet educational, interactive setting that allows our hospital customers to
learn from and network with colleagues who are encountering similar real-life benefit
challenges.
The hospital summit consists primarily of peer presentations by other hospital plan
sponsors, including presentations such as:
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Implementing a Domestic Provider Network & Reimbursement Strategy
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Is Your Health Plan’s Performance & Cost a Mystery to You?
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The Journey to Accountable Care Organizations
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Maximizing Your In-House Pharmacy Buying Power
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Let’s Play – Finding the Healthy, Active Child In Your Adult Employees
Those who participate in the summit tell us how appreciative they are to connect with
peers and learn new ideas and strategies to take back with them. In fact, 97 percent of
attendees over the past four years have rated the experience as “Excellent.”
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Plan designs to keep care in-house
As a hospital, one of your primary goals is to keep care within your hospital. A multitiered plan design is a common strategy for encouraging members to use your
domestic providers. The most common is a 3-tier plan, with services from domestic
facilities and providers paid at Tier 1, in-network providers at Tier 2 and out-of-network
providers at Tier 3.
UMR can administer plans with any number of tiers.
For instance, if your hospital is unable to provide a particular service, UMR can set up
your plan to pay for such services at the Tier 1, domestic, level to ensure your
employees and their dependents are not penalized.
Another option is to mandate that a specific service be provided at your hospital. For
example, you can set up your plan to require that members receive MRIs at your
facilities. Members still can receive an MRI at other facilities, but it would paid at the
Tier 3, out-of-network, level.
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Taking control of plan costs
UMR has the flexibility to allow you to set your own domestic reimbursement, providing
you more control over the bottom-line cost of your plan.
Doing so allows you to carve out your facilities and providers from the managed care
network and determines what level of reimbursement UMR will pay toward their claims.
UMR can administer a variety of domestic reimbursement methods, with the most
common being a percent of billed charges. Other available methods include:
•
Diagnosis-related groups (DRGs)
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Per diems
•
Resource-based relative value scale (RBRVS) fee schedules with a conversion
factor
Setting your own domestic reimbursement makes you less dependent on managed
care networks, reducing the potential ramifications should your relationship with your
network be severed.
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More money in your pocket
UMR is able to suppress checks for payment to your domestic providers and facilities
while capturing these transactions in all claims data.
Because your hospital’s funds are not suspended during processing and delivery, you
have more cash on hand. Increased cash on hand and improved cash flow can have a
positive impact on your bond rating, making you better able to secure funding for large
investments, such as facility expansion or new construction.
We can configure automatic payment suppression identified by hospital, domestic
facilities or physicians (or a combination of these) at a tax identification number level.
However, we cannot configure check suppression to include individual hospitals,
facilities or physicians, i.e., you cannot set up Dr. Smith with automatic payment
suppression and Dr. Jones with paper check payment.
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Care management
UMR Care Management provides integrated, member-centric services that
can be tailored to your overall strategy. We help employers develop multi-year strategies
to adapt their health culture to value healthy lifestyles, emphasize personal accountability
and, ultimately, mitigate their medical claim trend. We focus on educating and motivating
members, moving them from incentives for participation to incentives based on
achievement of empirical, clinical health markers, such as BMI, LDL, fasting glucose and
blood pressure.
We equip your plan members with the knowledge and resources to take a more active role
in their health care decisions and to think like consumers when choosing the right options
for them. UMR recognizes that when it comes to member care, one size does not fit all – a
service of utmost value to one plan member may be of little or no value to another.
Incentives, such as reduced co-pays or premiums, reward members for appropriate use of
high-value services or adopting a healthy lifestyle.
Government estimates show as much as 75 percent of health care costs can be attributed
to a preventable disease, so offering 100 percent coverage for preventive care may be a
sound investment. Preventive care, such as age- and gender-specific screenings, can
detect these diseases early, when they are most treatable, and help at-risk members make
healthy lifestyle changes to avoid developing a chronic and costly condition.
We can also offer value-based benefit solutions that combine the strength of our care
management programs with the benefits of consumer-driven health plans. The result is a
plan that uses incentives to steer plan members to the highest-value care at the most
affordable rates.
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The value of our care management
program
Our suite of care management products offer tightly integrated
internal solutions to medical management, but we also have the flexibility to “plug and
play” with just about any vendor a client prefers.
We can give you access to the full spectrum of URAC-accredited programs – from
utilization management and case management to disease management and health and
wellness.
Each program is interconnected and linked to our sophisticated claims platform. Or you
can pick and choose only those products that fit your unique needs.
To make the most of your medical plan and take full advantage of the discounts
available to you through the UnitedHealthcare Options PPO Network, UMR requires
you to use our utilization management and case management solutions to limit
potentially costly claims.
When purchased in a combined package, our customers typically realize a 3:1 return
on investment for our utilization management, case management and disease
management programs.
There’s no silver bullet to our approach, but it is designed to connect with plan
members and energize them to actively participate in their health care decisions and
lifestyle choices.
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Flexible care management
UMR understands many of the care management services we provide are also
available through your providers and facilities. We can customize our programs to
maximize the use of your domestic facilities, clinicians, programs and initiatives, while
interfacing with our care management services.
We offer two types of arrangements for coordinating our services
with your internal resources:
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Coordinated care management
•
Hybrid care management
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Coordinated and hybrid care
management
Coordinated care management - In this arrangement, UMR offers services that you can
provide in-house. Rather than duplicate efforts, we can coordinate those services with
your facilities and providers.
Hybrid care management - Under this more common arrangement, UMR will wrap its
care management services around your internal resources.
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Customized wellness programs
UMR can customize our health and wellness programs to your organizational culture, and
work with you to incorporate your internal resources.
For instance, you can conduct your own clinical health risk assessment and biometric
screenings and supply the data to UMR to identify members with current and future health
risks. We then can help you develop incentive and reward programs that work best for the
organization and your employees.
When working with hospitals and health care systems, one of the key concerns in
developing health and wellness programs is confidentiality due to the extreme sensitivity of
health-related information. We will work with you to integrate our internal resources and,
when necessary, provide solutions that will alleviate confidentiality issues.
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The member experience
UMR Care Management works with members to:
•
•
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Actively engage them in their health and health care decisions
Help them understand how to get more value for their health care dollars
Improve their daily behavior to enhance their quality of life
Members have an advocate who helps them navigate the health care system and their
benefits options in a knowledgeable, friendly and caring manner. Our programs
emphasize communication and education, participation, member satisfaction and
clinical improvement. Members receive the tools they need to build stronger
relationships with their health care providers, along with informative materials on
important health topics and access to online resources.
Working hand-in-hand with clients and client advisors,
we can drive participation through:
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•
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Preventive care coverage
Plan inclusions and exclusions
Incentives tied to clinical health risk assessment (CHRA) or biometric
screening completion and health status, or incentives tied to participation with a
health coach or case manager
We recognize that every member population is different, so we will work with you to
customize an incentive plan that best meets your needs and those of your members.
UMR care management provides a variety of member materials to help you introduce
the programs and services available to your employees and encourage them to make
healthy lifestyle choices. These include posters, flyers, tent cards, wallet cards,
teleseminars, newsletter articles and lab screening handouts.
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Rewarding healthy behaviors
The right use of incentives will help you:
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•
•
•
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Engage and reward members
Encourage completion of CHRAs and biometric screenings
Drive enrollment in health coaching programs
Spur interest in wellness-related activities
Influence behaviors
Maintain momentum
Place a clear emphasis on what’s important to the culture of your organization
Incremental, phased, multi-year strategies have proven most effective. Consider
rewards based upon:
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Activity/participation: Incentives for completing a CHRA or wellness
coaching
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Diagnosis/risk: Co-pays waived on condition-specific medications, i.e.,
medicine for hypertension management or cholesterol reduction
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Compliance: Lower premiums for non-smokers, 100 percent coverage for
preventive care or condition-specific care or medications
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Outcomes/health status: Incentives or benefits based upon biometric
screening results or improved screening measurements, or for achieving
specific health goals
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Identifying member risk
UMR Care Management uses diverse sets of data and advanced analyses to identify
members with current chronic health conditions and future health risks.
After collecting the data, we examine the stratified results, using algorithms based on
standards outlined by nationally recognized health organizations.
When we’ve identified at-risk members — catastrophic, chronic or at-risk (non-chronic)
— it is important to engage them in the right program through plan design and targeted
member communications.
Members in the following categories are targeted to participate in one-on-one sessions
with a health coach or nurse:
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One of seven disease states: asthma, chronic obstructive pulmonary disease
(COPD), congestive heart failure (CHF), coronary artery disease (heart
disease), depression, diabetes and hypertension
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Pregnancy
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High-risk for developing heart disease
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High-risk for developing diabetes (pre-diabetes)
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Multiple lifestyle risks (nutrition, activity, blood pressure and/or weight/obesity)
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Tobacco use
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Body mass index of 35 or more (morbid obesity)
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NurseLine® and maternity management
NurseLine connects members with highly trained registered nurses any
time of day, seven days a week. Nurses help callers make more informed choices
about when and where to seek the appropriate care, providing information on specific
conditions and treatment options. This can result in fewer emergency room visits and
hospital stays, leading to lower overall health expenses.
Through NurseLine, members also can access an audio health information library, with
more than 1,100 recorded topics, such as aging, common illnesses, fitness and
surgical procedures.
Our maternity management program offers assessments and
information for women considering having a baby and prenatal education and guidance
to those expecting. The result is an increased number of healthy, full-term deliveries
and a decrease in costly, extended hospital stays.
We identify participants using claim edits, triggers and utilization review. Our nurse
coaches then provide education, follow-up calls and support based on
the woman’s individual risks. Those identified as high-risk are placed
into our case management program, to monitor their conditions
and keep customers informed of high-cost situations.
All members who join the maternity management program during
the first or second trimester receive an incentive gift. Once enrolled
in the program, expectant mothers are contacted by nurse case
managers who have extensive clinical backgrounds in obstetrics/
gynecology. Members also can choose from a selection of highquality books and other materials containing helpful information
about pregnancy, pre-term labor, childbirth,
breast feeding and infant care.
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Health and wellness
UMR’s health and wellness program provides a proactive
approach to improving the health of employees. We identify members’ current and
future health risks and then help them understand those risks and how they are linked
to conditions such as diabetes and heart disease. We give them the tools and support
to make healthier lifestyle choices that reduce their likelihood of developing a chronic
disease.
Completing a clinical health risk assessment (CHRA) is the first step for members. Our
CHRA asks questions about members’ medical history and lifestyle habits such as food
choices, physical activity level, tobacco use and readiness to change.
We combine the CHRA reports with biometric screening results for blood pressure,
glucose levels and cholesterol to gain a more complete picture of the overall health of a
group. Members identified as high risk for future health problems are invited to work
with a personal health coach in a series of one-on-one phone conversations. Our
coaches are trained in behavior-change techniques and provide information and
encouragement to help participants set goals and follow through with their plan to live
healthier.
UMR can assist you in establishing a workplace culture that supports healthy behaviors
to improve the well-being of your employees. We provide strategies and support in
crafting customized wellness plans, along with employee challenges that encourage
participation in physical activity, weight loss or healthy eating programs.
We encourage customers to attach incentives to their wellness programs. Incentives
increase participation and have a direct impact on your program’s success. Because
every employer population is different, successful incentive programs are structured
with the particular motivations of the members in mind.
The program includes:
Clinical health risk assessments
Onsite biometric health screenings
Personal health coaching
Quarterly newsletters
Educational information
Worksite wellness strategies and support
Incentive administration
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Disease management
UMR has found that these seven health conditions drive
medical claims costs for employers:
•
•
•
•
•
•
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Asthma
Chronic obstructive pulmonary disease (COPD)
Congestive heart failure
Coronary artery disease
Depression (co-morbid condition)
Diabetes
Hypertension (high blood pressure)
Identifying plan members and helping them manage their conditions provides the
maximum value to you, while helping participants improve their well-being. The
program also can mitigate indirect costs to you, such as absenteeism and reduced
productivity.
Our program uses the leading behavior change model to determine an individual’s
current stage of readiness to change and how we can best guide the participant toward
improved health. To maximize your short-term return on investment, we focus on those
who are currently most ready to make a healthy change. Members with a chronic
condition are automatically enrolled in the program, and those identified for one-on-one
coaching are invited to participate through a combination of letters and phone calls.
To help drive participation in the program, UMR offers customers new to disease
management a $100 gift card incentive. It is given to eligible members who enroll in
one-on-one coaching during an introductory time period.
Lower-risk participants receive
a free subscription to our
quarterly newsletter and periodic
communications about their
condition and making healthy
changes.
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Case management
UMR case management targets complicated cases to achieve better
medical outcomes for plan members and greater cost savings to you. The key to our
success is the case manager’s ability to identify, coordinate and negotiate alternative
treatment plans and related costs.
•
•
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Our case management team is made up of licensed, registered nurses
95 percent of our nurses have certified case manager (CCM) credentials
All must have three years of acute care clinical experience and expertise in at
least one specialized field
Our system identifies case management opportunities using an automated trigger list
that can be customized at your request. The list is based on ICD, CPT and dollar
threshold criteria or when a member’s inpatient length of stay reaches five days. Each
case is unique and handled according to the specific needs of the
member. On average, cases remain open for four months.
UMR measures the success of its case management
program by the following criteria:
•
•
•
•
•
•
•
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Improved clinical efficacy
Reasonable medical action plan
Coordination with providers and family
Clinically eligible for coverage
Customer satisfaction correspondence
Coordination with stop loss vendors
Return on investment
Tangible results
UMR Care Management can provide data to support cost savings
based on risk reduction through comparison of behavior change and clinical outcomes.
Our programs put an emphasis on communication and education, participation,
member satisfaction and clinical improvement. As a result, customers achieve a
measurable return on their investment, including participation, clinical, utilization and
financial results.
When purchased in a combined package, our customers typically realize a 3 to 1 return
on investment for our utilization management, case management and disease
management programs.
In 2010, UMR’s book of business showed that for members who completed
health coaching:
•
•
•
•
•
•
39 percent improved their physical activity frequency
25 percent state they have less life stress after coaching
32 percent stopped tobacco use during coaching
34 percent showed improvement in blood pressure
44 percent stated they eat high-fat foods less frequently
44 percent stated they eat high-fiber foods more frequently
By working with UMR’s health coaches, disease management participants overall are
able to improve or maintain their health status for nearly 75 percent of the clinical risk
factors measured.
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Pharmacy
Whether you choose to maintain a retail pharmacy within your hospital, you have unique
opportunities as both a purchaser and dispenser of prescription medications.
UMR’s preferred pharmacy benefits manager, OptumRx, has worked with customers to
transform their inpatient pharmacies into retail outlets for employees and their
dependents. This arrangement can open the door to new revenue and give employees a
convenient option for filling prescriptions onsite.
You can choose from a variety of plan designs and pricing strategies to control costs and
encourage employees to use the domestic pharmacy, keeping revenue within your
organization. These strategies can help you take advantage of discounts available on
prescription drugs and allow you offer a national wrap network that best meets the
pharmacy needs of your plan members.
You also have an experienced PBM to oversee prescription drug utilization for your plan.
Make the most of your pharmacy.
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Our preferred PBM partner
In this kind of environment, you need a pharmacy benefits manager that knows the
business, has the financial backing and access to state-of-the-art technology only a
Fortune 50 company can provide and has the mindset of building infrastructure around
the client and consumer.
UMR found this expertise right in the family — OptumRx. As the largest health-planowned PBM, OptumRx (like UMR) can bring much more to the table than a typical
stand-alone PBM. In addition to strength and depth of skill, OptumRx offers
accountability for not only pharmacy outcomes but also the effect those decisions have
on your medical benefit.
Both UMR and OptumRx are proud to be part of UnitedHealth Group. Our businesses
are organized into two arms — UnitedHealthcare, which contains the core medical
businesses, including UMR; and Optum Health Services, which is composed of the
health services businesses, including OptumRx.
This close association makes it easy to understand why OptumRx is our preferred
pharmacy benefit manager. We are tightly integrated, have access to the same
committed investments of UnitedHealth Group and present a unified approach to
serving the full spectrum of our clients’ needs.
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A full spectrum of PBM services
OptumRx is an innovative, full-service pharmacy benefit management company,
managing the prescription drug benefit of commercial, Medicare and other
governmental health plans, as well as those of employers and unions.
From claims processing to clinical services, rebate management to network
management, OptumRx takes pride in bringing excellence throughout every service we
provide.
OptumRx now serves more than 13 million members, translating to approximately 21
million members due to the size of our Medicare Part D segment. Those members
typically take 2.5 times more medications than a commercial member. Last year,
OptumRx processed more than 350 million adjusted scripts, which makes us the
fourth-largest PBM in the nation.
Our business-wide generic penetration was at 74.6 percent in first quarter 2011, and
mail order generic penetration at 74.4 percent in first quarter 2011 – positioning us as
one of the industry leaders in generic utilization rates.
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By the numbers
One important key metric is our
Net Promoter Score (NPS),
which we calculate internally
every month. NPS is critical
because it measures a member’s
word-of-mouth recommendation
of a service. NPS is defined as
the percent of promoters minus
the percent of detractors while
ignoring the passives.
We use a 5-point scale from
Completely Satisfied to
Completely Dissatisfied for
the question “Would you
recommend OptumRx to a
friend or family?” Our current
Net Promoter Score is 64.6 percent.
To level set, net promoter scores for most companies are between 5 percent and 15
percent; high-performing companies such as American Express are usually around 40
percent to 45 percent.
In 2009, JD Power did an NPS analysis and based on adjusted data. We were at 66.2
percent at the time, and our Big 3 competitors were at 36 percent (ESI), 31.1 percent
(Medco) and 29.4 percent (Caremark).
According to a 2010 Satmetrix NPS analysis, comparable scores to ours list eBay at 65
percent, Facebook at 65 percent and Google at 63 percent. Apple leads the NPS space
at 78 percent.
The folks promoting us are dispersed throughout very different market segments as we
serve employers, labor unions, TPAs, PBMs and MCOs.
When clients work with both UMR and OptumRx, we receive consistently higher
customer satisfaction rates than groups without OptumRx as their PBM.
Our surveys show that when a plan has integrated benefits, we see a four-point
increase in overall satisfaction. Better accuracy, faster turnaround, members who are
treated with respect and coordinated warm call transfers drive this satisfaction.
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An integrated team
Clearly the relationship between OptumRx and UMR is
strong and connected, offering clients that integrated support as part of the
UMR team.
For instance, your OptumRx client relations manager will take care of your day-to-day
operational needs, while your OptumRx strategic account executive will ensure you are
satisfied and that we are meeting your overall strategic goals and needs.
We are grounded by strong business development and sales executive support.
Because if we are strong — you are, too.
And finally, the UMR client service coordinator and SAE are there to enrich the
customer experience even more — ensuring the health/medical plan branches are farreaching and intertwined with the pharmacy benefits.
In a true client partnership model, we need to define a balance between all the moving
factors to create an appropriate benefit plan for our customers. It’s a balance between
cost savings and member disruption; how can we maximize your savings with the least
amount of disruption to your membership? OptumRx has the flexibility to build a
customized pharmacy benefit plan to hit the right balance for you.
Together, we will determine which programs to implement that will address consumer
needs and maximize satisfaction, while driving value to the overall benefit strategy.
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Pricing flexibility
You have three choices of pricing:
1.
Fixed fee:
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OptumRx passes through the ingredient cost and dispensing fee charged by
the pharmacy, without mark-up
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The plan knows what they pay their PBM – a fixed, per-paid claim fee
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The plan does not need to negotiate with OptumRx to receive improved terms;
the plan receives them as soon as the renegotiated pharmacy contract takes
effect
One point to consider, the pricing arrangement looks different and can be difficult to
explain and contrast with the traditional model, so it may not be the best strategy or fit
for all plans.
2. Traditional:
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The plan receives guaranteed and predictable discounts and rebates
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Traditional is the most widely used pricing model in the PBM industry
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Easy to explain to clients and generally viewed as a low-risk option
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The plan trades predictability of fixed discounts for disclosure of PBM revenue
and transparency
3. Rebate Fee Credit:
•
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Reduction to UMR’s TPA administration charge, instead of rebate payments
The advantage of OptumRx + UMR
The long standing history between UMR and Optum Rx
strengthens us with several key differentiators, including:
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A single financial process – The human resources manager receives one combined
feed for reporting, data and eligibility.
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Nightly HDHP/HSA FSA auto-reimbursement feed – Information is updated in real
time, so members receive FSA information sooner.
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Stop loss (aggregate and individual) pharmacy data integration feeds sent several
times per year – Reimbursement is sent to the customer in June or July, versus the end
of the year.
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DM/CM/wellness data integration – Customer service can view real-time pharmacy
information with members enrolled in these programs.
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Coordinated call center – Our integrated call centers and warm transfer technology
allows for an holistic approach to member services; the member can make one call and
manage all their medical and prescription benefit inquiries.
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One ID card – Members have the convenience of one ID card to hold all their important
Plan ID numbers and service center information.
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Member portal – Members need to access only one Web site to see all important
medical and pharmacy benefit information.
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Flexible benefit design – We match the needs of the plan with a customized benefit
design.
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Client service model – Our dedicated service team partners with the UMR service team.
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What people are saying about OptumRx
Our own industry validates our value, consistently awarding
us for our investments and service philosophy.
•
2010 URAC Best Practices Award in Health Care Consumer Empowerment and
Protection for its Multiple Sclerosis Disease Therapy Management Program –
One of only two platinum awards (and the only one given to a PBM) for our innovative
member outreach program that improves outcomes and reduces costs. Additionally,
we are the first PBM to earn all four URAC Pharmacy Quality ManagementSM
accreditations.
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2011 LearningElite Award – This is similar to the ASTD BEST award. We won a
2009 ASTD BEST Award from the American Society for Training and Development
(ASTD) for our Customer Advocacy initiative, becoming the first PBM to be so
honored. The initiative features innovative, interactive curriculum with hands-on
activities, role playing and simulations.
•
Top 1 percent of companies nationally and highest among peers in 2010 JD
Power Customer Call Center satisfaction survey – We showed best-in-class
among all 12 mail pharmacy call centers with an overall score of 870. OptumRx
received the highest rankings for customer service and cost competitiveness factors
among mail order pharmacies in the J.D. Power and Associates 2009 National
Pharmacy Study. We ranked second overall among mail order pharmacies, and were
one of only two mail order pharmacies to receive all five Power Circles, which equates
to “among the best” for the overall experience.
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Third consecutive TIPPSSM Re-Certification for Pharmacy Benefits
Transparency Standards – We received re-certification for Transparency in
Pharmaceutical Purchasing Solutions (TIPPS) from the HR Policy Association
Pharmaceutical Coalition, earning the coalition’s highest level of transparency by
providing actual average inventory cost for mail order drugs. Certification is bestowed
only upon PBMs that are willing to meet the Coalition’s rigorous transparency
standards and agree to provide Coalition members with audit rights to validate
compliance.
We received the prestigious Verified Internet Pharmacy Practice Sites™ (VIPPS®)
reaccreditation by the National Association of Boards of Pharmacy® (NABP®) for web- based
pharmacies in Carlsbad and OPS. We won Gold for Best eBusiness Site from the eHealthcare
Leadership Awards in 2010 and a 2009 Gold MarComm award for writing/Web copy. Plus
the WilsonRx Survey placed us as the top mail service pharmacy two years running, rating us
No. 1 nationally in overall member satisfaction for two years in a row.
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Stop loss
UMR has strong relationships with the nation’s leading stop loss carriers. Our preferred
status earns customers premium discounts. Just as importantly, customers experience
fewer handoffs and encounter fewer of the complications that can occur when you use
more than one vendor.
By using our arrangements, customers can work with financially stable carriers who are
committed to the stop loss market. Our customers receive preferred pricing because of
UMR’s ability to provide access to the UnitedHealthcare networks and our proven cost
containment programs. Customers have access to plan mirroring provisions, avoiding
coverage gaps between their medical plan documents and stop loss policies.
Our claim turn-around guarantees are the best in the industry. Our customers are able
to have carriers lock in rates sooner than the industry average, which allows them
access to unique programs, such as three-year contracts, Raising the Bar and Contract
Advantage Plan (CAP).
CAP is a policy endorsement offered by HCC Life. It guarantees that if the customer
renews, the renewal policy will not contain any additional covered persons with a
separate individual-specific deductible (i.e. laser). Specific monthly premium rates on
the renewal are guaranteed not to increase by more than 12 percent over the current
rates. The group must purchase CAP upfront; it is available for additional premium.
The UMR advantage gives customers integrated and
immediate claim notification, so you can get a
jumpstart on managing high-cost claims.
Our support features include weekly claim filing of new and
subsequent claims, electronic claim filing and select carrier
system integration and low document filing requirements.
Our support also includes an industry-leading Stop Loss
Activity Monitoring (SLAM) notification and trigger reporting
that includes online and drill-down with daily updates.
UMR gives direct carrier access to in-house care management
resources for prognosis updating. We send final plan documents
and amendments to carriers for you.
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MyStopLossCenter.com
To stay on top of your stop loss activity, just click on
the myStopLossCenter tab at www.umr.com. You’ll gain
immediate access to current and prior year stop loss activity, as well as aggregate and
specific stop loss reports.
myStopLossCenter allows you to view specific stop loss claims. With stop loss claim
inquiry you can see:
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Employee and claimant name
Policy number
Claim type
Carrier
Contract type
Requested, denied and received amounts
Dates requested and received
Stop loss deductible
And, UMR’s automated e-mail notification will keep you informed of any activity for
your account.
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Client and member service
At UMR we don’t just aim at service excellence. We deliver it.
Our Customer First business model ensures accountability is embedded across your
service team. I’ll get into the detail of our implementation model but let me assure
you—the detailed approach means we get it right the first time.
We take our time training the customer first representatives (CFRs),starting with six
weeks in the classroom followed by a full month on the job with limited authority,
concentrated audits and close mentoring.
And as we administer your plan, we conduct individual audits in claim and call. Each
CFR has five calls recorded every week to review service accuracy and quality. We
conduct a corporate audit of each service office to make sure our company standards
are met for processing accuracy.
UMR provides monthly and sometimes even daily or weekly reports for claim
transactions, check registers, and even care management and (if you opt for
Optum Rx) prescription usage online. We supply quarterly standard reports as desired
using Advantage Suite by Thomson Reuters and an annual Plan Performance Analytic
Review which merges clinical findings with claim costs and trends against normative
data for application in strategic planning or benefit modifications.
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Delivering service excellence
UMR has developed a specialized training program to help
our customer service teams understand the complexity of hospital benefit plans so they
can provide superior service to you and your members.
The program includes training on:
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Multi-tier plan designs
Custom provider networks
Direct contracting
Hospital self-pay
Referrals
Telephone and e-mail etiquette
Organizational mission and culture
We have designated three service locations as Hospital Centers of Excellence, where
we administer benefits for more than 90 percent of our hospital customers. Our
approach drives accountability and results in timely and accurate claims processing
and attentive service.
We invite you to participate in the installation process for your benefit plan. Take the
opportunity to meet your claims team to set expectations and educate our CFRs on
your hospital’s capabilities and organizational structure.
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Member support
Our operations model is built around the plan members and customers to meet their needs
in the most efficient manner. Taking care of plan members is critical to plan sponsor
satisfaction, so we concentrate on providing accurate, fast and compassionate service.
Each client is assigned a dedicated team that’s focused on accuracy and turnaround.
They get to know each plan in detail and often get to know members by name.
CFRs answer the phones and pay claims so they have all the information they need to
respond quickly to a call. We find this approach results in more than 90 percent of
inquiries resolved on the first call. On average, each CFR has more than six years of
experience and takes ownership for their customers.
The CFRs are joined by customer specialists who solve day-to-day claim issues and work
with experts throughout UMR to maintain quality in our daily operations. We maintain a
ratio of 2,300 plan members to one CFR. The team also includes a claim supervisor.
Care management nurses, as well as disease management and wellness coaches,
provide members with ongoing support to live as healthy a life as possible. Our care
management is integrated with claim operations, so UMR provides seamless member
interaction that increases first-call resolution.
If a client chooses consumer-driven (CDH) plans or value-based benefit designs, UMR
offers a trained Consumer Concierge to act as their advocate and provide cross-functional
customer service (medical, CDH and dental), beginning at pre-enrollment and continuing
throughout the life of the plan.
Our pharmacy services partner, OptumRx, has dedicated UMR resources and userfriendly Web and mobile tools to boost member compliance. UMR also has strong online
tools to help members keep track and understand their benefits and monitor not only their
claims but their own health.
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Customer support
On the plan sponsor side, each customer has a dedicated strategic account executive (SAE)
who becomes an expert on that client’s culture, objectives, benefit strategy and expectations.
SAEs hold an authoritative role within the UMR structure. They are able to influence decisions
and provide superior, proactive service in managing accounts. Bilingual SAEs are available.
SAEs are accountable for their client’s overall satisfaction and:
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Partner with clients and their advisors in enhancing their plans and savings through
ongoing analysis and regular results meetings
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Are a single point of contact for escalated issues and liaison between clients and UMR
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Have self-funding knowledge
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Hold a strong partnership with account executives
SAEs are supported by customer specialists who:
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Solve day-to-day claims issues and escalated, complex customer service challenges
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Work with experts throughout the organization to maintain quality of daily operations
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Provide technical expertise to the team
Client service consultants support the SAE and, of course, the client in service delivery. They:
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Support clients and their SAEs in day-to-day questions or issues
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Partner with the SAEs in service delivery and tasks for the account
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Are key facilitators for tracking, fact gathering, and information delivery such as reports,
contracts, plan summaries and ID cards
©2012.
Specialized support
Customer First teams have access to specialized teams who designate contacts by
customer to increase accountability and familiarity.
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Reporting and analysis – provides access to online reports supporting
financial reconciliation and facilitating strategic decision making
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Care management – integrated with claims operations, which creates
seamless member interaction and increases first-call resolution
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Ancillary services – provides access to best-in-class ancillary services,
including vision, hearing and telemedicine products
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Stop loss – focuses on delivering the best carrier and contract type with quick
claims filing and reimbursement
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Consumer-driven solutions – a comprehensive approach that increases
consumer engagement while reducing overall medical trend
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Claims – dedicated team that’s focused on accuracy and turnaround while
working to maximize your savings on today’s claims costs
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Network administration – focused on maximizing the access and savings
associated with local, regional and national networks
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Pharmacy benefits -- a preferred relationship with our sister company
OptumRx offers the best integration, flexibility and lower prescription costs.
©2012.
Customer First delivers results
Customer First teams drive accountability, resulting in
timely, accurate claims processing as shown by the
results below. We also externally validate our results through annual SAS70
audits. We audit 3.5 percent of our claims.
Additionally, we conduct regular customer satisfaction and account management
surveys, provide performance guarantees and use consistent feedback metrics.
UMR’s auto-adjudication rate is greater than 75 percent, and more than 70 percent of
our claims are submitted electronically, which further improves accuracy.
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A reputation for smooth
implementations
Transitioning to a new TPA can sometimes be a barrier to making a change. At UMR, we
understand how important a smooth implementation is, and we pride ourselves on a
successful and — if we say so ourselves — impressive track record.
We assign experienced transition leaders who oversee a
full team that includes:
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The strategic account executive
Claim management
Supervisors
Technical experts from each of our business units
All our teams, and especially our transition leaders, are experts at dealing with unexpected
issues without jeopardizing their deliverables.
We keep detailed implementation logs, assigning each and every deliverable and task a
target date and an owner who is held accountable. Management also plays
an active role.
As the implementation moves along, this team evolves into an ongoing service team — so
they understand the issues and the complexities of your plan better than anyone else.
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Reporting
UMR offers more than the UnitedHealthcare network advantage. With capital
investment, we are also able offer state-of-the-art reporting capabilities so you can
measure just how effective your plan is and where your money is going. With UMR’s
customized, on-demand reporting, you can leverage industry and national benchmarks
to measure your plan’s trend.
UMR will provide you with in-depth plan analysis and recommendations to support
continuous improvement and strategic decisions. We offer predictive technologies to
support targeted, proactive health and wellness programs. And, our online resources
are available 24/7, so you can access reports at your convenience.
UMR offers integrated and detailed reporting through
several tools.
Our online reporting tool—InfoPort—provides daily, weekly, monthly or quarterly
reports, according to your preference.
Thomson Reuters Advantage Suite© (formerly known as MedStat) is a Web-based
analysis tool for medical, pharmacy (if available) and enrollment data. You have access
to extended data analytics with slicer/drill capabilities and extended benchmark
information. This tool offers 32 reports with exploring capabilities and is easy to export.
It offers condition and Major Diagnostic Category information and provides rolling 24month data, paid and/or limited incurred. Benchmark data (called MarketScan®) is
based on 31.5 million lives.
Finally, our data services provide claim extract setup or FTP-Internet file transfers. We
support one-time ad hoc reports, data requests and production reporting.
Additional UMR custom support is available for:
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ASA-certified reserve/
IBNR estimates
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Customized benchmarking
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Ad hoc reporting
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Stewardship analysis
reports
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Predictive modeling
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Episode cost/quality
profiling
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Care management reporting
(if using UMR’s internal solution)
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InfoPortSM – online reporting tool
InfoPort allows you to not only monitor plan performance but identify trends and outliers
through analyses of three or more years of UMR data.
You can access information on claims, benefit utilization, financial activities, network
performance and enrollment. Transactional data is updated daily, with only a twobusiness-day lag.
InfoPort allows you to drill down by group, benefit level, benefit plan, class, coverage
tier, location, member ID, patient relationship and more. We have report designs with
multiple report layouts, and you can customize report criteria, allowing you a myriad of
reporting options. Even better, you can save your own customized templates.
You can run reports on incurred and paid timeframes. And, you can create, run and
view your reports on demand. You can also schedule recurring reports with dynamic
dates. Report data is available in PHI and non-PHI versions. Also, you can easily
export your reports to multiple formats, such as Excel, PDF, and Word.
Available reports include:
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Census: enrollment; summary
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Extracts: claim level, claim service level, enrollment census
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Claim: detail, lag, summary, summary by member/network/provider,
summary service level
©2012.
Advantage Suite® – online reporting tool
For an analytical overview of claims, UMR offers Advantage Suite®, an online reporting
tool created and maintained by Thomson Reuters.
While not a financial tool for reconciliation, Advantage Suite (formerly called Medstat)
can help you analyze health care costs, utilization, quality and performance trends and
measures. You can drill down to product line/plan, region, metropolitan statistical area,
employee status, relationship, location and coverage tier. You can compare your costs
and utilization to robust geographical and industry benchmarks.
Advantage Suite, which is updated monthly, shows gross claims. It does not include
stop loss information or administration fees. Reports are run based on paid dates or
incurred dates, and standard reports can be modified to conduct ad hoc analyses.
You can see trends in medical and Rx data, compare
against benchmarks, track preventive and chronic
conditions and identify cost drivers.
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Hospital-specific plan analysis
UMR offers a specialized reporting package designed to meet your unique information
needs as a hospital. The quarterly report is an extension of the Thomson Reuters
Advantage Suite© and provides detailed plan data related to demographics, financial
performance and utilization.
The hospital reporting package also provides valuable benchmarking data against
UMR’s hospital book of business and the health care industry pulled from Thompson
Reuters’ MarketScan® Commercial Claims and Encounters database.
Detailed plan analysis gives you the tools you need to make informed strategic
decisions to ensure your health plan meets its goals. Available reports provide
extensive data delineating domestic, in-network and out-of-network cost and utilization.
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Online services
UMR’s Web portal gives you one online source for all your benefits needs. There’s no
need to remember multiple user names and passwords, because you don’t need
multiple accounts.
Such easy access to all UMR products encourages
members to actively participate in all aspects of their
health plans.
Members can look up:
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Medical claims and benefits
Dental claims and benefits
Flexible spending account
information
Pharmacy claims through
single sign-on
access to OptumRx
Care management information
Employers and brokers can find
information on:
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Medical claims and benefits
Dental claims and benefits
Flexible spending accounts
They can also access:
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OptumRx reports
Stop loss claims and reports
Subrogation reports
Enrollment
UMR is not reliant on third-party development or canned solutions for our Web
capabilities. We develop our solutions in house, so we can be as flexible as you need
us to be and respond faster to your needs.
To find information about our products and how we do business, visit www.umr.com.
That’s where members, employers, providers, client advisors and partners go to
access a wealth of services. Information is kept confidential and secure. Users must
register and log into the portals, allowing us to verify their identities.
We also want you and your plan members to easily navigate the site. Any problems or
lag time can be resolved through a toll-free phone call.
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Features for employers
These features are all just a click away:
For a demo of the Employer Information Center:
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Logon to www.umr.com
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Select “employers”
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Enter group number: 76888888
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When prompted for username and password, use:
Username: demoemployer
Password: secret1
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To search for employee information, use Member ID: 088000001
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For Check Register, use dates 10/01/2002 – current date
©2012.
Features for members
For a demo of the Member Information Center:
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Logon to www.umr.com
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Select “members”
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Enter member ID: 088000001
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When prompted for username and password, use:
Username: demoemployee
Password: secret1
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Our value to you
In summary and to repeat, UMR offers hospitals an
advantage no one else in the industry can offer.
UMR helps hospitals:
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Provide quality health care to employees and dependents while effectively
managing plan costs and employee productivity
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Maximize their return on existing hospital resources
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Reduce the administrative burden of the employee health plan
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Recruit and retain talented health care professionals
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Identify new services to better meet demand and increase competitiveness
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Develop stronger relationships with their physicians
©2012.