Clinical Processing Outsourcing

ABOUT DBSA’s Clinical Processing Outsourcing

Clinical Process Outsourcing (CPO) is the newest addition to the growing global business of DBSA. It will cater to the rapidly growing industry of outsourcing health care management.

Managed care and healthcare delivery system in the United States have been quoted as costly and most often inefficient. DBSA-CPO is set to provide a distinct and integrated package of medical management solutions which can be tailored fit to support the clients’ needs and achieve their business goals.

OUR MISSION

DBSA-CPO Healthcare is dedicated to deliver quality medical management solutions by combining the following key pointers:

Develop streamlined processes and create innovative ideas that will optimize medical management operations.

Reinforce proper communication to maintain a healthy working relationship between business partners and team members.

Aim to provide a group of professionals with a wide range of medical knowledge and clinical expertise.

Keep seamless transition of processes by mirroring the client’s system and at the same time, ensuring compliance with security and privacy of information.

Enable clients to enhance productivity, improve efficiency, and reduce unnecessary spending by ensuring that each work is delivered on time and at its best.

WHY WORK WITH US?

DBSA-CPO offers global medical management solutions which can help improve clients’ profitability and productivity by aligning the people, process, and technology.

1. PEOPLE – Being part of Drake International, our biggest advantage is being widely recognized as a global human resources solutions provider, with over 60 years of industry experience. Having the proven screening and recruiting model, we are able to know and find the best and brightest health care professionals. As such, given our large pool of contracted medical personnel (particularly nurses) in our network, we are set to accommodate projects of varying scope, may it be large or small.

Overview of our healthcare professionals:

  • They are graduates of Bachelor of Science in Nursing, with wide medical knowledge and clinical expertise.
  • They are familiar and knowledgeable with the US healthcare delivery system, Workers’ Compensation, Health Insurance Portability and Accountability Act (HIPAA).
  • They have excellent English speaking and writing skills, as well as strong customer interaction skills.

2. PROCESS – We practice the act of knowing the client’s business needs first.

  • We believe that our client’s valuable insights can help us come up with a process that will meet the requirements of their business goals.
  • Although our sole focus is the managed care industry in the United States, we take pride in developing processes that can be tailored fit, making sure that we are uniquely qualified to meet the outsourcing needs of all types of health care organizations.

3. TECHNOLOGY – Being part of Swiss Post Solutions, we have ventured into becoming a premium provider for business processes solutions, innovative services, and technology.

  • Health care security, compliance and dependability are our high priorities and we ensure that client data is securely safeguarded and all staff adheres to all privacy laws.

CORE CLINICAL SERVICES TO OFFER

MEDICAL MANAGEMENT

1. Intake Services

  • Data entry, sorting, organization, categorization, and listing in the client’s system.
  • Preliminary clinical reviews for utilization review cases to ensure medical necessity and appropriate protocol.

2. Utilization Management

  • Review of patient records by telephone or online to determine medical appropriateness of treatments in line with the approved guidelines
  • Review of requests not fully adjudicated
  • Pre-certification and authorization of services prior to hospital or outpatient facility admission
  • Appeals assessment using client-specific guidelines to ensure appropriate administration of benefits
  • Provider representation for pre-authorizations
  • Retrospective reviews for quality assurance

3. Telephonic Services (Inbound/Outbound)

  • A 24/7 direct in– and out-bound telephonic interaction with our clinicians in order answer all questions regarding clarity of physician orders or patient medical records, confirm demographic materials for patients or providers, request additional information or address any other matter in accordance with our client’s policies and procedures.

4. Disease Management

  • A telephonic interaction with our clinicians wherein they provide medical teaching in order to manage chronic diseases. They help patients learn to avoid potential problems and exacerbation, or worsening, of their health problem.

5. Nurse First Response

  • A telephonic injury triage hotline in wherein our clinicians provide nursing expertise within minutes of a workplace injury.

WORKERS’ COMPENSATION

Medical Bill Review

  • By using the client’s specific systems, our health care professionals will be able to eliminate unnecessary costs of overpaid reimbursements as well as unreasonable and inappropriate charges.
  • We will ensure quality, propriety, and appropriate reimbursement based on the medical records, explicit knowledge of treatment, and prospective authorization provided.

Utilization review

  • DBSA will provide utilization review services by allowing our nurses to complete first level medical review of claims (whether it is prospective, concurrent, or retrospective) in order to identify the medical necessity of requested procedures.  
  • Each review will be done in accordance with national and evidence-based guidelines and coordination with Client’s Physician Advisors.

Case Management Support

  • Scheduling appointments
  • Following up on test results
  • Filing medical and patient progress reports
  • Summarizing medical reports
  • Contacting providers

Telephonic Case Management

  • Establish and implement return to work plans for our client’s injured workers through telephonic communication.

Case File Preparation

  • Summary and medical record chronology preparation, as well as proper guideline application.

DISABILITY

Absence Management

  • DBSA will help employers to manage absences that can result in significant savings – from identifying ways to shorten disabilities, reduce incidences of absence, the need for replacement workers, and lessen lost productivity.

Return to work

  • DBSA will help both employers and employees to certify disability as needed and to identify claims that could benefit from the development of a return to work plan. Our nurses will carefully monitor progress, while ensuring positive communication and involvement from the employee.

OTHER SERVICES

Medical Coding

  • Our certified medical coders will review medical records and transform healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes or standard codes using CPT (Current Procedural Terminology), ICD-9 0r ICD-10 (International Classification of Diseases), and HCPCS (Healthcare Common Procedure Coding System) classification systems.

Demand Package Review (Property & Casualty Liability Claims)

  • Our Professional Nurses will review the medical records submitted and provide a narrative in order to identify the medical necessity and causal relatedness of the treatments given and determine which of these can be reimbursed.
  • We will also perform automated bill review based on the determinations provided by our Nurses.

Risk Assessment – Underwriting

  • Our healthcare professionals will evaluate the risks of insuring a particular person and uses that information to set premium pricing for insurance policies.