Pharmacy Benefit Management (PBM) Ancillary Services Settlement Solutions

Transcription

1 Press Kit

2 Sparked by the merger of Progressive Medical and PMSI, Helios has provided solutions for workers compensation and auto no-fault cost containment for nearly 40 years. Our proven, integrated solutions include: Pharmacy Benefit Management (PBM) Ancillary Services Settlement Solutions The systemic combination of these three programs creates a synergy of information that results in more control, better outcomes, stronger compliance, a healthier patient, and a healthy bottom line. 1

3 About Us Helios is bringing the focus of workers compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs the injured person. We provide our services from first fill to settlement with a passion, focus, and intensity on delivering value beyond just the transactional savings for which we excel. Our products and services enable better decisions and achieve better outcomes. They get injured people the right medications, products, services, and settlements at the right time. They reduce program costs by avoiding payments for medications and services that should not be paid, pairing robust analytics with veteran clinical expertise, and leveraging our operational flexibility. All of this leads to brighter insights, greater savings, and fewer claims. Website: LinkedIn: Media inquiries: Colleen Stoker [email protected] Headquarters Florida Ohio Utah 6410 Poplar Ave., Suite 800 Memphis, TN Kelsey Lane Tampa, FL Progressive Way Westerville, OH West Price River Dr. Price, UT Lake Park Blvd., Suite 300 Salt Lake City, UT

4 PMSI founded. PMSI acquired Tmesys to create first wholly-owned workers compensation retail pharmacy network. PMSI acquired Health Advocates, Inc., a leader in Medicare Set- Asides. PMSI published first Annual Drug Trends Report. PMSI launched MyWorkComp mobile app. Progressive Solutions and PMSI merge PMI introduced first retail drug card. PMI launched IFX, first claims management portal PMI and SRPS joined to form Progressive Solutions. PMI launched Ventrix ancillary provider ranking system. PMI introduced first injury-specific formularies Helios launched into the market. Progressive Medical (PMI) founded. 4 StoneRiver Pharmacy Solutions (SRPS) founded.

5 COMPANY VITALS Industry-leading provider of customized, innovative, and clinically-focused solutions for workers compensation and auto no-fault Pharmacy Benefit Management (PBM), Ancillary services, and Settlement Solutions. Most experienced workers compensation-specific program in the market, managing more than 7 million prescriptions annually. Serve more than 1,000 clients, including many of the country s largest insurers and third party administrators (TPAs). More than 1,400 employees across the country in six office locations: Memphis, TN (Headquarters); Tampa, FL; Westerville, OH; Salt Lake City, UT and Price, UT. Three business units supported by integrated account management, clinical, informatics, technology, marketing, and government affairs functions. Industry s only wholly owned, directly-contracted retail pharmacy network, Tmesys, which includes nearly 70,000 pharmacy locations nationwide. Only fully integrated Medicare Set-Aside (MSA) and PBM vendor. In-house clinical management tools and solutions provide targeted clinical analysis, intervention programs, formulary management, thought leadership, and continuing education services. Award-winning, patent-pending analytics. Recognized leadership and advocacy in Government Affairs. 5

6 At Helios, we have a passion for doing what s right, for our clients, the injured person, and the industry. That is why we are always looking for brighter solutions to meet the challenges in the workers compensation and auto no-fault industries. This passion inspires us to reshape the way things are done into the way things should be done. And, of course, to never stop working toward even better solutions. 5

7 INSIGHTFUL SOLUTIONS Pharmacy Benefit Management The Right Medication at the Right Time Helios Pharmacy Benefit Management is laser-focused on doing the right thing. This intensity has sparked innovations that increase cost control by decreasing the personal impact of an injury. Our services: Make filling a prescription easier through a directly-contracted network that includes nearly all of the nation s pharmacies Capture more prescriptions in-network, achieving up to 98% retail network penetration and reducing administrative burden in the process Ensure the injured person receives the right medication at the right time with veteran clinical expertise Mitigate potential high-risk, high-cost situations Excel with advanced technology and reporting, and patent-pending, advanced analytic insight We have built our carefully crafted, deliberately synchronized program on a strong foundation: a fully redundant, secure technology and service platform. On top of this, we overlay injury-specific Medication Plans and formularies, drug utilization review criteria, and client-specific business rules. These criteria feed our proprietary electronic adjudication platform, keeping data and communication flowing between pharmacy to payer, lighting the way forward to better outcomes. 7

8 INSIGHTFUL SOLUTIONS Ancillary Products and Services Quality Care Coordination Secures the Right Path The right Ancillary services can be as important to quality care as the right prescription. Our comprehensive Ancillary services are easily navigated and provide a vast network of carefully-vetted, quality providers. We carefully investigate each provider candidate before adding them to our network. This attention to detail makes certain that high-quality, professional services are cost-effective and readily available, regardless of location or complexity of needs. Our program includes: Medical Equipment and Supplies Home Health Care and Infusion Therapy High Exposure Claim Services Comprehensive Coordination of Care, 24/7/365 Translation Services in over 120 Languages Nationwide Transportation Services Catastrophic Care Physical Medicine Diagnostic Services Inpatient Negotiations 8

9 INSIGHTFUL SOLUTIONS Settlement Solutions Integrated Medical, Pharmacy, and Claims Knowledge Achieves the Right Settlement Helios Settlement Solutions has been called best-in-class, and for good reason. When you use Helios for both PBM and Settlement Solutions, you ll maximize overall savings. Helios has been at the forefront of compliance for both the Medicare Secondary Payer (MSP) Act, and Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of Our programs mitigate potential barriers to settlement, facilitating interventions that pave the way to settlement. We focus on both the cost and use of medical services and pharmaceuticals throughout the claim lifecycle to ensure compliance and transition to settled claim. We help you achieve accurate and cost-effective compliance, resulting in timely and appropriate care for the injured party. Our MSP compliance programs include: Medicare Set-Aside (MSA) Allocations MSA Fund Management Clinical Cost Containment Solutions Claim Forecasting Mandatory Insurer Reporting 9

10 Brighter Solutions. Better Outcomes. 9

11 LEADERSHIP Emry Sisson Co Chief Executive Officer John Bencivenga Chief Legal Officer David Farmer Chief Financial Officer Eileen Auen Executive Chairman Thomas (Tommy) Young Co Chief Executive Officer Mike Brandenburg Executive VP of Operations Barry Jarnigan Chief Marketing Officer Brett Drexelius Chief Sales Officer Jay Krueger Executive VP of Strategy Tron Emptage, RPh Chief Clinical Officer Andrew Lewis Executive VP of Human Resources 11

12 SUBJECT MATTER EXPERTS Brian Allen Joe Anderson Jessica Bartell As vice president of government affairs, Brian Allen serves as an advocate for both payers and injured workers alike. He monitors legislative and regulatory issues around the country in an effort to influence positive change in the workers compensation industry. With more than 20 years of experience in government relations, Brian delivers valuable insight on current and pending legislation, case law, jurisdictional and federal regulations, and other topics that affect injured worker outcomes. As the director of analytics, Joe Anderson researches ways to utilize data to develop new services for our clients. These innovative programs utilize historical pharmacy data to predict which injured workers will have long-term pharmacy spend, or long-term complications with prescription drug use or addiction issues. As vice president of provider relations, Jessica Bartell manages the development of the company s medical equipment, health services, ancillary, and specialty services provider network. In her role, Jessica negotiates contracts and pricing schedules with vendors to get the best possible pricing solutions for our clients. Additionally, she oversees two large ancillary customer contracts working to ensure their service and contractual obligations are met. 12

13 SUBJECT MATTER EXPERTS Tron Emptage, RPh Kelli Falter Matthew Foster, PharmD As chief clinical officer, Tron Emptage oversees our comprehensive suite of clinical programs designed to help payers gain more control over medical costs to achieve better outcomes for injured workers. Tron leverages two decades of pharmacy and managed care experience in developing and managing key program components, such as medication plans and formularies, utilization reviews, physician outreach, clinical intervention, and pharmacist and nursing support. The use of these programs by our customers ensures injured workers receive the right therapy at the right time. As the manager of provider relations, Kelli Falter manages and develops our ancillary provider network, ensuring that injured workers receive adequate coverage and a high quality of care and product at the best price. As clinical pharmacy manager, Dr. Matthew Foster oversees our clinical services production team that is responsible for all of the prescriber intervention services that help ensure the right medications are being utilized at the right time. He also works closely with our clinical liaisons and design teams to provide enhanced and new clinical services for Helios clients. 13

14 SUBJECT MATTER EXPERTS Rafael Gonzalez, Esq. Jeff Gurtcheff Robert Hall, M.D. As vice president of strategic solutions for settlement, Rafael Gonzalez serves as a thought leader on all aspects of Medicare and Medicaid compliance issues, including Mandatory Insurer Reporting, Conditional Payment Resolution, Medicare Set-Aside Allocations, CMS approval, and professional administration. 14 As the vice president and general manager for settlement, Jeff Gurtcheff is responsible for clinical cost mitigation programs for settlement purposes, Medicare Set-Aside allocations, conditional payments, MMSEA Section 111 Reporting, structured settlement services, and post settlement programs, to include professional administration. Jeff s team is comprised of pharmacists, registered nurses and life care planners, attorneys, and seasoned claims professionals that work diligently to protect our client s assets and be compliant with Medicare s Secondary Payer requirements. As corporate medical director, Dr. Robert Hall advises our customers and employees on evidence-based clinical and rehabilitation guidelines that optimize our pharmacy, home health, and durable medical equipment programs to promote better outcomes and earlier return-to-work for injured workers. He also offers counsel on our processes and procedures to identify and reduce prescription medication misuse and abuse.

15 SUBJECT MATTER EXPERTS Brooke Mueller, PharmD Kevin Tribout As a senior clinical pharmacist, Dr. Brooke Mueller manages the Drug Testing and Monitoring (DTM) service provided by Helios. In this role, Brooke provides training and direction to the pharmacists in assessing inconsistent drug test results, and providing communication to the prescriber regarding recommendations on how they should follow up with the results to the claimant. As executive director of government affairs, Kevin Tribout spearheads our client education, communication, and compliance programs on the latest legislative and regulatory initiatives. He reviews the impact of legislative and regulatory issues, ensures compliance across all business units, and acts as a direct liaison to state legislators and regulators on behalf of the company. Kevin also assists the Settlement division with influencing changes in the CMS Medicare Set-Aside allocation processes at the federal level. 15

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