MCS has been providing Third Party Administration services to employers since 1975. With offices in Quincy, MA, Ravenswood, WV and East Orange, NJ, MCS provides high quality benefit plan administration to employers throughout the U.S. Our technology and benefits expertise enables us to provide the most cost effective group medical, dental, prescription drug, vision care, and disability income plan administration to employers ranging in size from 15 to thousands of employees.

MCS offers our clients a wide array of administrative services including:

• Medical/Dental claim administration

• STD Administration

• National PPO access

• Comprehensive utilization review products

• Rx administration

• Section 125 administration

• COBRA/HIPAA administration

• Healthcare Savings Account (HSA), Healthcare Reimbursement Account (HRA) and other consumer driven healthcare plan administration 

Our highly trained professionals provide personal attention to each of our clients and their employees. In 2001, 90% of our claims were processed in under 5 days, while the majority of member’s calls were answered in less than 40 seconds.

Our commitment to technology enables employers to administer their benefit plans with less staff. The MCS claims system can receive claims electronically and provide twenty-four hour access to providers for eligibility verification through both the Internet and Interactive Voice Response (IVR). Electronic claims typically have all the information necessary for proper claims adjudication and facilitate timely and more accurate service for your employees.

Our technology permits Employers, with multi-state locations, to offer one plan of benefits to all its employees. MCS can coordinate multiple PPO’s throughout the United States to provide uniform cost effective benefits.

MCS’ investment in technology enables us to provide the highest degree of accuracy in claims processing at the lowest possible cost! Some of the benefits are:

For the Employer

1.     Eligibility – Enroll/delete plan participants in real time. Hard copy of enrollment forms can be scanned directly into our system!

2.     On demand claims reports – Claims reports are posted to the MCS website monthly. An e-mail notification is sent to our employer clients notifying them of the availability of the reports.

3.     Electronic invoices by MCS – MCS will send an e-mail invoice notification directly to your Human Resources and/or Accounts Payable Department directing them to our website for the downloading of our invoice.

4.     Check “loss fund” balances – Employers can monitor their own balances to insure the timely payment of claims. MCS can also provide e-mail notification when balances need to be replenished.

5.     Review your Plan Document, Summary Plan Description (SPD) and MCS Administration Manual on-line at any time.

6.     Research medical conditions and determine “best treatment options.”

7.     Order ID Cards on demand.

For the Employees

1.     Enroll over the Internet in employer sponsored benefit plans.

2.     Check on status of Medical/Dental/Flexible Compensation claims.

3.     Select a PPO Physician/Dentist.

4.     Advise MCS of address changes, student status, addition/deletion of dependents.

5.     Order ID Cards.

6.     Review your personal claims history.

7.     View Summary Plan Description (SPD).

8.     Research medical conditions and determine “best treatment options.”

9.     Order prescription and non-prescription items through on-line drug stores.

10.  View list of “America’s Best Hospitals.”

11.  View health/wellness information.

12.  Pre-certify a proposed hospital stay.

Health Care Management

MCS is focused on managing the entire “health care dollar” for our clients, therefore we have selected to partner with only the highest quality managed care service providers.

Our partners are leaders in the medical management industry, they take a patient-centered approach that promotes wellness, helps reduce lost workdays and increased member satisfaction. At the same time, they help reduce expenses. Building on a broad portfolio of seamless integrated products and services, a seasoned team of clinicians and managed care experts recommend high-impact programs that best serves you and your plan participants.

 You can expect an extensive range of medical management services, including:  

§        Flexibility and scalability to apply the right programs for a specific population.

§        Reliable, consistent service through our national network of clinical professional resources.

§        Value-added member services such as Internet-based health information through a secure website – healthinfoseeker.com – to empower consumers by giving them the tools they need to prevent illness or injury.

§        Commitment to better outcomes as well as comprehensive, user-friendly customer reporting.

§        Caring, experienced nurses with ongoing training in current medical research and best practices.

§        Commitment to quality as evidenced by American Accreditation.

HealthCare Commission/URAC Health Utilization Management Accreditation, Case Management Organization Accreditation and Health Call Center Accreditation.

 24 Hour NurseLine

Today’s health care consumers want to know that someone is on their side. Available around the clock, our experienced, caring nurses provide a convenient – and highly credible – first point of contact for plan participants who have health care questions or concerns. Nurses answer questions, explain medical options and suggest resources. They encourage plan participants to receive timely care in the most appropriate setting and support these suggestions with clinical information. For best results, our clear, easy-to-understand employee communication tools encourage program use.

A recent study of nearly 1 million eligible users shows that when plan participants use the 24-hour health information line, health care costs are significantly lowered for seven our of 10 outpatient conditions. In fact, in almost every case when members call, costs are reduced – either immediately or in the long run. The service encourages users to pursue healthy behaviors. As a result, they miss fewer workdays because of illness and appreciate an employer or plan provider who furnishes this tremendous resource.

Utilization Management

Utilization management programs address the full spectrum of inpatient and outpatient health care therapies and settings. From straightforward inpatient review to identification of potentially complex cases for management, we offer a comprehensive selection of integrated services to promote efficient use of health care resources and optimal outcomes. 

The goal is to keep employees healthy by making sure that they obtain the right care at the right time in the right setting by your provider. Our utilization management services set an industry benchmark for quality, and our ability to integrate review services with a complete portfolio of case management, disease management and other programs sets us apart from other health care management companies.

Maximize ROI by tailoring a program that matches the coverage you offer and monitors the services and settings that employees or members use most.

Case Management

When a serious illness or injury occurs, our partner knows that managing for quality will result in the most effective care and-in the long run-control costs. They have an unsurpassed national network of telephonic and on-site nurse case managers to coordinate care, stem costs and promote optimum outcomes. Armed with industry-leading guidelines, they draw on their medical knowledge and familiarity with local and national resources to coordinate quality care and reduce case costs. And they respond quickly-because there’s no time to wait. 

The breadth and scope of these case management services allow them to navigate cases throughout the entire continuum of care. To optimize health and productivity outcomes, our nurses use a coordinated, patient-centric approach that addresses the patient’s needs, the diagnosis and prognosis, the care environment and available alternatives.

These case management programs deliver maximum impact when integrated with our other health care management services.

Disease Management

Chronic diseases exact a terrible toll on patients and their families and cause millions of lost workdays each year. Chronically ill employees account for annual charges that are three to five times higher than other employees. Disease management programs encourage individuals diagnosed with diabetes, heart disease or asthma to actively manage their health. These programs aim to reduce lost work time and hospitalization while promoting a better quality of life.

Working closely with patient and physician, nurses develop a customized personal care management plan, with goals and recommendations to support continued progress toward maximum health and productivity. Changes are measured and reported in four key areas:

§        Clinical results

§        Financial impact

§        Behavioral changes

§        Participant satisfaction

Maternity Management

Pregnancy is a time of both joy and concern. Maternity management programs provide early identification of potential risk factors and helps expectant mothers take measures to ensure a healthy delivery and a healthy baby. Through a detailed screening process, we differentiate between first and subsequent pregnancies and gestation to tailor information that will have the most impact. The program includes a wealth of health and lifestyle resources to help expectant moms, and their families, prepare for the baby. For mothers-to-be who smoke we offer membership in a smoking cessation program geared specifically for pregnant women. This program promoted better outcomes for expectant mothers and their babies, while helping control pre- and post-natal health care costs. Maternity management is available as a fully integrated component of utilization management or as a stand-alone service.

 Network Access

MCS has contracted with PPO networks who have demonstrated an ability to provide our members with the ultimate mix of provider access and network discounts. In areas where one of national partners may have a void, we have the ability to access a local solution.

In addition to primary PPO network solutions, MCS has also contracted with overlay networks. These networks offer passive discounts for those claims that may fall out of network. It doesn’t stop there for those claims that fall outside of the primary PPO and the overlay network we have a managed care department committed to negotiating claims. In 2001, this department saved our clients 21.6% of claim dollars reviewed.

Express Scripts

Express Scripts reduces unit costs for prescription drugs by negotiating discount rates with our networks of retail pharmacies across the country. The PERxSelect network offers more than 53,135 participating pharmacies nationwide, while the PERxCare network contains over 45,217 pharmacies for more significant cost containment.

Express Scripts offers two national networks covering more than 99 percent of retail pharmacies nationwide and maintains 53 EPO networks and 268 customized networks. 

PERx Card Program 

Express Direct^SM 

Network Access 

PERx Card Program

Express Scripts' PERx Card Program is a National Preferred Provider Network based on cost-effective principles of managed care that include discounted negotiated pricing and online claims adjudication. This option is best for members who need short-term (less than 30 day) prescriptions. Unlike "provider-based" card plans that are driven by the pressures of retail marketing and pricing, PERx Card participating pharmacies must agree to discounted reimbursement, superior quality, online data based technology and extensive member eligibility control. These networks offer varying levels of access and discounts. Our networks of conveniently located participating pharmacies, combined with informative, easy to use management reports, allows Express Scripts to make a real difference in the quality and cost of the drug benefit. 

Express Direct^SM 

Plan sponsors who want the cost savings of a managed pharmacy benefit program while maintaining current major medical drug coverage may opt for ExpressDirect. With this program, members enjoy Express Scripts' discounted prescription drug prices at network pharmacies. The member pays the pharmacist 100% of the negotiated network price. The pharmacist conducts a pre-dispensing, online claims adjudication procedure to verify eligibility and an online concurrent drug utilization review (DUR). Claims may either be submitted to Express Scripts or to the member's own carrier. Express Scripts provides claim activity on tape to the client. 

Network Access 

Network Access allows plan sponsors and members to rent our nationwide network of pharmacies. With this program, members enjoy Express Scripts' discounted prescription drug prices at network pharmacies and benefit from online, concurrent drug utilization review (DUR) conducted by the pharmacist. The member pays the pharmacist 100% of the negotiated network price. The pharmacist conducts a pre-dispensing, online claims adjudication procedure to verify eligibility and an online concurrent DUR.

Reports

MCS recognizes our clients need information to make crucial decisions regarding the employee benefit plan. We pride ourselves on providing our clients with the most timely, accurate, concise information on their plans experience. All Standard Reports (listed below) are available via hard copy or on our website, www.medicalclaimsservice.com. In addition to the standard reports, MCS’s claims system allows us to develop ad hoc reports to meet the changing needs of our clients.

Standard Reports Include:

 §     Check Register – Provides detailed payment information on all checks issued for a specified group(s) by range of dates.

§      Detailed Claims Report – Lists individual claims by participant including total charge, provider, ineligible/discount amount, deductible, coinsurance, COB savings and paid amount.

§      Claims Analysis Report – Summarizes paid claims by participant including total charges, ineligible/discount amount, deductible, coinsurance, COB savings, paid amount and claim count.

§      Claim Activity Report – Lists medical claims paid by month and year-to-date for subscribers and dependents for the Stop Loss plan year.

§      Service Code Analysis – Summarizes paid claims by service code including total charges, ineligible/discount amount, deductible, coinsurance, COB savings and paid amount.

§      PPO Service Analysis – Summarizes paid claims by service code for PPO network and out of network charges.

§      Paid Claims by Diagnosis Group – Summarizes the number of patients, number of claim lines, total charges and total paid amounts by diagnostic group.

§      Claims Lag Report – Provides a table of dollar payments on claims incurred, cross-referenced by month paid.

§      Turnaround Time Report – Summarizes the number of claims processed by the number of calendar days since receipt of the claim.

§      Age Banded Census Report – Provides the number of male and female participants with single or family coverage in five-year age bands.

§      Lifetime Maximum Report – Summarizes the amount accumulated towards the plan lifetime maximum by participant.

§      Eligible Expense Report – Summarizes paid claims by dollar intervals of eligible expense amounts including number and percentage of claimants and expenses at each interval.

§      Analytical Reports – Provides the option to create Custom utilization reports including hospital and surgical charge analysis, top 30 provider charge summary, paid and charge amounts by diagnosis and demographic breakdown of claim charges.