Overview
TMG Health is the leading provider of Business Process Outsourcing (BPO) services to the government health programs market including support for Medicare Advantage, Part D, Medicaid Managed Care, SCHIP and group retirees. TMG Health provides strategic and component outsourcing solutions for health plans, provider-sponsored plans and self-sponsored employers with large retiree groups.
TMG Health is the largest and most experienced BPO vendor serving the managed Medicare market segment, with a broad solution set serving dozens of health plans totaling more than 2.8 million members in all 50 states. Our clients range from large, multi-state or national plans with hundreds of thousands of members to small, regional plans with less than 2,000 members. We serve 14 Blue Cross Blue Shield plans and both for profit and not for profit plans. All of which adds to a broad understanding of the critical success factors needed to survive and thrive in this challenging marketplace.
KEY BENEFITS
Advantages to partnering with TMG Health include access to our advanced and innovative systems, rapid implementations, ongoing process updates to address CMS requirements and industry best practices, reduced capital costs, fixed operational costs and proven regulatory compliance.
Using TMG Health BPO services to help administer government health programs products provides a number of key benefits for Health Plans in this competitive market.
IMPROVED CONTROL OVER PRODUCT ADMINISTRATION
TMG Health constantly monitors operations utilizing industry best practices and provides transparent oversight of our activities. Clients have direct access to our systems and performance measurements. Performance measures are driven by CMS compliance requirements as well as items unique to each client. Industry "best practices" assure products are administered with successful, effective and repeatable processes. Improved control is also achieved via a focused and accountable organization dedicated to your success.
ASSURED COMPLIANCE
A Health Plan cannot delegate its compliance obligations, but by leveraging TMG Health's ten-year history and national experience, our goal is to make compliance "easy" for Health Plans. TMG Health's culture is "to act like a Health Plan" which includes staffing of a Chief Compliance Officer, a full Compliance Department, creating a comprehensive Compliance Plan and having quarterly Board of Directors reviews. We offer clients a national compliance perspective that few individual Health Plans have. TMG monitors all CMS Directive communications (Guidance and Transmittals), ensures timely and complete adherence for all that apply to operations that we administer and provides ongoing communication of the status to our clients.
REDUCED OPERATING AND CAPITAL COST
TMG Health offers Health Plans a means to deliver high quality, differentiated government health products with low, predictable administrative costs. TMG offers much lower "fixed" capital cost relative to the volatile costs associated with internally administering these products. Equally important is the fact that outsourcing services from TMG Health offers Health Plans a more strategic way to allocate both their staffing resources and capital. Clients can optimize their resources on other, more critical and competitively differentiating initiatives.
BUSINESS AGILITY
TMG Health's proprietary applications and business processes result in a responsive and industry "Best Practices" environment. Our unique "home-shoring" staffing model, flex staffing programs and employee skills cross-training deliver a business model that can react quickly to unexpected membership growth or the compressed operational demands of Annual Election Period (AEP), surveys and other seasonal events. TMG clients are relieved from having to make large capital investments in technology or infrastructure to remain competitive in the government health programs market and can re-direct those funds to other projects granting them greater financial flexibility to meet new challenges.
KEY VOLUMES AND PERFORMANCE METRICS
TMG Health's National Operations and Data Center serves over 2.8 million Medicare and Medicaid members. Our operation has been built to be cost-effective as well as flexible and scalable to address the member and process volatility unique to the government health programs marketplace. Using a state-of-the-art managed care information system in combination with over a dozen internally developed, proprietary applications, we offer a highly specialized environment designed to support the unique challenges and process of Medicare Advantage and Medicaid products. Key operational volumes and performance metrics include:
- TMG Health serves over 30 separate health plans and insurers in 50 states and Puerto Rico
- 2.8 million Medicare Advantage, Part D and Medicaid members served
- 3.5 million calls handled annually
• Average speed of answer <5 seconds
• Average abandonment rate < 2%
- Over 20 million claims processed
• 100% of clean claims processed in 30 days
• 90% of clean claims processed in 15 days
- 16.5 million statements, ACH and remits produced
DESCRIPTION OF SYSTEMS AND SERVICES
TMG Health was founded on the value proposition of providing operational cost savings, state-of-the-art technology, enhanced quality and performance, regulatory expertise and an easily identifiable return on investment for its clients.
The scope of the service offering is broad and clients can elect to outsource the majority of their operations to TMG Health (Strategic Outsourcing) or start off with outsourcing selected non-critical functions (Component Outsourcing). By partnering with TMG Health, a Health Plan can leverage TMG Health's proven outsourcing solutions to support any of the following operations:
- Enrollment Processing and CMS Eligibility Reconciliation
- Premium Billing and Delinquency Processing
- Claims Mailroom, Imaging, OCR Adjudication, EOB, EOP, Checks/EFT
- Provider Capitation Payment
- RAPS Claim/Encounter Data Submission
- Member and Provider Call Services (Inbound and Outbound)
- Health Risk Assessments and Working Aged/MSP Surveys
- Medical Management System Support and Consulting
- Mail Fulfillment Services
- Data Extracts and Interface with Plans and Vendors
- Management, Performance and Financial Data Reports
- CMS DOI /HIPAA/HEDIS Compliance Programs
MANAGED CARE INFORMATION SYSTEM AND PROPRIETARY APPLICATIONS
To succeed in today's highly competitive health care environment, organizations need the right technology to provide effective health care solutions. TMG Health utilizes the TriZetto Facets® managed care information system selected specifically for its powerful and flexible claims processing functionality. The system's highly advanced, state-of-the-art plan/server technology delivers performance, flexibility, speed, and robust scalability. Facets® is integrated with a number of TMG Health's proprietary software applications specifically designed to meet all CMS and state regulations as well as all contracted functional requirements. In addition to being compliant, TMG Health proprietary systems are specifically designed to address Medicare Advantage product operations and optimize performance.
- TMG Enroll - Medicare Enrollment processing application
- TMG Resolve - CMS TRR transaction automation and workflow
- TMG Recon - CMS MMR transaction automation and workflow
- TMG Bill - Comprehensive premium and subsidy information process
- TMG Call - Integrated Call Services application
- TMG KEyS - Customer Service survey data capture
- TMG Knows - CSR Knowledge Database
- PROFix - Claims Preprocessing Edits to ensure high first pass claim rates
- PROCIaim - Claims workflow management and image distribution system
- TMG WKI - Web capture interface for claims, enrollment, surveys, etc.
- OCR - Tailored imaging/data capture software
TMG Health provides access to our managed care system and proprietary modules in order to assist our clients in monitoring operations delegated to TMG Health. Our clients have a fully transparent view of everything TMG is doing to administer their products. Additionally, managed care information systems modules for non-delegated functions performed by the client plan such as Care Management and Appeals & Grievances, can be remotely accessed by our client's staff. These modules have full integration with TMG processed data (e.g. claims or call information) allowing a client's staff member to have a comprehensive view of member data.
TMG Health is responsible to fully configure Facets and our proprietary applications to meet CMS and State requirements. We maintain them in accordance with changing client policies and procedures, benefit structure and provider contracts and CMS and state regulations.
PERSONAL SERVICE / PROVEN PROCESSES
From the start of implementation through plan go-live and ongoing operations, clients are supported by a dedicated team representing various TMG Health departments. Consistent interaction and communication between TMG Health employees and our customers results in a partnership arrangement rather than a simple vendor relationship.
TMG Health is audited annually to ensure compliance with SAS 70 Level 2 requirements. Our systems and processes have been stress tested over the years and have been proven to be cost-effective, accurate and scalable. Over the past 10 years we have developed a proven and fully vetted implementation and conversion methodology. We have successfully launched products for more than 40 Health Plans and assisted dozens of others to migrate from internal systems and operations or from other outsourcing vendors. TMG Health's implementation and conversion processes are managed by an experienced Project Management Office using the experience of TMG's best practices and the Project Management Institute (PMI) Body of Knowledge standards. We offer product-specific implementation plans that are built on experience but fully customized to the unique requirement of each client's situation. We review lessons learned from each implementation or conversion and build this into a continuous improvement process.
For every client, TMG Health develops a customized Governance Structure built on a unique set of contract commitments and Service Level Agreements (SLAs). A dedicated Account Manager oversees the governance model and provides continuous feedback to their client regarding operational performance and issue management.
SUMMARY
The government health programs market has changed over the past 10 years and the rate of change is only expected to increase in the coming years. TMG Health has the experience, the systems, the personnel and the processes to help Health Plans weather these changes. With over ten years of experience and with focused dedication to this marketplace, we help our clients remain compliant and competitive in an increasingly challenging industry. To date we have helped over 50 Health Plans successfully enter this market and have helped them grow to support over 2.7 million members.
As the largest BPO provider dedicated to this market, we offer Health Plans a means to mitigate the risks normally associated with the government health programs market. Using TMG Health to outsource all or part of your Medicare Advantage, Part D, Medicaid and/or SCHIP products will help you to be more cost-effective and be assured of compliant operations.
