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Computer
System
Automated
Claims Payment System, Island Group's automated
claims payment system, was designed expressly
for our requirements and the needs of our clients.
It is a fully automated, on-line, interactive
system that is both flexible and versatile and
able to meet the needs and growth of our organization
as well as our clients. The system adjudicates
medical, dental, vision, Flex 125 and worker's
compensation claims. In addition, the system automatically
accommodates any type of benefit features including
PPO claims, interactive UCR tables, managed care
provisions, etc.
The
Island Group, Administration Inc. computer system
is a UNIX based system. Unix is recognized the
world over as one of the most stable and versatile
operating systems in existence today. This system
can upload and download data from most standard
OS environments and has full data exchange capabilities.
Our claims adjudication system in proprietary
and was created to meet to needs of IGA and our
clients. We have yet to reach the limitations
of this system, if any. In addition, we have had
virtually no down time to date. Our system is
year 2000 compliant, and has been certified by
both software and hardware vendors. This system
is fully capable of batching claims into a "single
episode of care.". This system is fully capable
of automatically detecting:
- Overpayments
- Potential
Fraud
- Provider
fee unbundling, up coding, aberrant billing
- Quality
of care concerns
- Potential
case management
- Appropriate
R&C schedules
There
are no limitations or restrictions in our claims
administration system and network operations that
would prohibit or limited our efficient claims
processing. A full description of internal quality
control and auditing procedures was conducted
and addressed areas of investigation, frequency,
qualifications of auditors (internal and external),
follow-up on negative findings, method of audit,
etc. IGA conducts hospital bill audits on a routine
basis.
Island
Group Administration does maintain geographically specific
"reasonable and customary" (R&C) charge
screens for all practitioner fees and medical procedures
(e.g., HIAA, MDR). Our current out-of-network and optional
indemnity plans use HIAA as well as MDR at the 90-95th
percentile. The choice of percentile is generally discussed
with the Plan Sponsor at the time of account setup.
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