A New Employee Benefit Management Company Model

CAPITOL ADMINISTRATORS is a company with a vision. . . to be an employee benefit administration leader. We specialize in the design and administration of custom self-funded health, dental and vision benefit plans. Today's environment requires more choices and more complex benefits strategies; we must strive to provide advanced administrative solutions at competitive rates. The keys to operational success are simple:

Processing claims efficiently and timely A quality customer service department capable of responding to employee/provider questions with equal efficiency and timeliness Accurate and timely reporting Quality business partners Competitive rates and claims cost controls

It is Capitols approach to addressing these needs that sets us apart. Our current client base has come from national and regional health plans and TPAs because they understand the value of our services.

CAPITOL'S SERVICE MODEL

Traditional health plans and TPAs constantly struggle between keeping their operational costs in check and providing the manpower necessary to address ever-changing inventories and new group demands. Month-to-month staffing needs directly impacts overhead and performance.  Employee development and training is expensive and time consuming. Temporary staff can jeopardize service quality. What is CAPITOLS solution? Capitol utilizes a one-site model that optimizes management communications and eliminates costs and inefficiencies of the typical national multi-site TPA model. On-site UR intake coordinators can promptly notify Capitol of potential large claims. Proactive communication between departments helps to eliminate claims or plan design issues. Customer service and processing staff cross-train and communicate regarding day-to-day issues to enhance services. Cross-training as well as written policies and procedures are mandatory in every department to assure service consistency regardless of staffing fluctuations. Comprehensive implementation procedures and extensive documentation requiring client approval assures correct plan design and interpretation.

ADVANCED TECHNOLOGY AND SYSTEM INTERFACES

At Capitol, Data Entry and Re-Pricing Departments have been replaced with Scanning, OCR and Electronic Re-Pricing practices that eliminate manual keying and input errors. Claims are scanned directly into our Rims System and electronically re-priced within 48 hours of receipt.  Plans are built to achieve high levels of auto-adjudication. Electronic data files are submitted to our subrogation business partner, which maintains access to Rims to assist with investigations. Custom software insures out-of-network claims are electronically submitted to our out-of-network business partner for discounts. (This process usually suspends payment for only 24-48 hours.) Our processing system interfaces with our UR/Case Management partner's system. Data is downloaded nightly. Custom software produces weekly large claim reports. Claims inventories are kept artificially low using on-call off-site processing resources as necessary. Claims are processed electronically without paper shuffling.  Only experienced Rims trained processors capable of maintaining high accuracy and production levels are used.  Strict auditing assures accuracy levels are maintained. With off-site processing resources we eliminate disruption in service levels associated with acquisition of new business. HIPAA compliant internet services provide access to EOBs, plan design(s), PPOs PBMs, and eligibility. Members and authorized HR representatives can ask questions or order replacement ID cards on-line 24/7. Utilization of our web-based services (with over 25,000 inquiries in 2003) has substantially reduced our customer service call volume. Statistically low inventories and high accuracy rates further reduce customer service call volumes.

COMPETITIVE RATES AND CLAIMS SAVINGS

What has allowed Capitol to be competitive in today's market? How can Capitol reduce claims costs? The one-site model and our ability to tap into processing resources based on actual inventory rather than projections significantly impacts overhead. Prompt and accurate claims processing reduces duplicate submissions, adjustments and customer service inquiries, which will also impact our bottom line. Advanced technology allows us to efficiently and systematically address claims loading, re-pricing, and customer service via the internet.  Custom software and internal systems identify and flag fraud and abuse and suspected fraudulent providers. System logic identifies duplicates; inappropriate bundling, unbundling and coding; multiple procedure charges; non-medically necessary, experimental or ineligible services; and inappropriate assistant surgeon charges. Custom software and automation identifies subrogation and out-of-network claims and allows Capitol to establish lower dollar thresholds (equating to additional claims recoveries). Out-of-Network claims are processed before submission to our out-of-network partner to assure discounts are based off savings achieved after application of R&C levels and other deductions. Discounts are thus based on true savings. Many PPOs inflate their savings reports by making calculations based off billed charges. Capitol acts as a service integrator contracting with the best and most competitive business partners. As a privately held company Capitol is free to recommend or contract with service providers based upon capabilities and competitiveness. We are not forced to offer bundled services due to ownership affiliations. Capitol's responsibilities are to its clients, not its shareholders. We have established relationships with national, local and customized PPO networks to obtain the deepest claims discounts possible. In addition, Capitol, not a parent company, controls its rates and profit margins.