How castlestone works

www.advancecons.com

Preventing Fraudulent

Transactions in Health CareHow Castlestone’s VisitEye Works

May, 2014

1 www.advancecons.com

Key Elements

• Setting up Castlestone’s VisitEye in 60-90 days:

• Visit Eye Integration

• Visit Eye Transactions

• Castlestone’s VisitEye in Operation

• Cost and Implementation Considerations

• Typical results


Setup: Integration - purposely limited using secure FTP file transfers

and standard queries/updates to plan sponsor

Providers sFTP

Member Status

Batch Updates

Standard Queries

Download of Transactions sFTP

Plan sponsor

Card Status• Create

• Replace

• Cancel

• Update

VisitEye


Set-up: VisitEye Transactions – ID cards, POS transactions,

Customized analysis

Plan sponsor ID Cards

with mag stripe

Rules for

POS keystrokes

Customized Analyses/Reporting

& Card-to-claim matching

Created and distributed

cards

Management of the card

base:• Issuance,

• Cancellation,

• Replacement

Combinations of POS keyed

transactions, card type, POS

location create plan sponsor-

specific actions for service

provider and plan sponsor. E.g.:• Swipe terminal eligibility alerts and

reports

• Chart review for power mobility

equipment

• Swipe and claim at doctor

compared to lab tests,

transportation bills, etc.

VisitEye Portal

• Swipe transactions details

• Pre-configured reports,

e.g.:• Card # lookup

• Approved transactions

• Rejected transactions

• Providers/Suppliers

• Ad-hoc reporting

capabilities


Set-up: About Card Issuance

• Compliant to health plan standards for card/track

encoding, and allows for standard printing

• Existing manufacturer contracts can be used

• Graphics and text remain the same; the plan

sponsor initiates any change

• Castlestone assigns 16-digit card network number

• No PHI and no financial value

• Plan sponsor or administrator updates card status

(add/change/replace/cancel)

– Can change card status from portal

– Castlestone implements the change

• Plan sponsor can also opt for delivery verification

and other anti-fraud measures


The patient swipes personal insurance I.D. card, with a Castlestone mag

stripe, in the same terminal used for credit card transactions

At the:

• Merchant

• Provider

• Physician

• At home

1. Patient

swipes card


That card is verified as is the terminal owner, location, merchant

code, transaction and time stamp

2. Data on Card ID, Terminal Owner, Terminal Location

Merchant Code, Transaction Code, Time Stamp

At the:

• Merchant

• Provider

• Physician

• At home

1. Patient

swipes card

(via credit card network infrastructure)

Castlestone runs rules against each

swipe, in real time, e.g.:• Do we know that swipe terminal in

our database of providers?

• Is that swipe terminal a medical

merchant code?

• Has that card been reported lost or

stolen? Are there restrictions?

• Has that card been swiped today at

another location?


These data are matched versus existing claim and prescription

records



3. Claim Matching

• Recipient name

• HealthPlan ID

• Provider IID

• Existing Rx for Class II drug?, etc.

At the:

• Merchant

• Provider

• Physician

• At home

1. Patient

swipes card

Health Insurer’s Analytics

(Can include FPS-like analytics)

Card Swipe DetailsCard Number: 5424176022824317

Name: Mitchell Clark

HealthPlan ID# 6789b

Provider ID# 0077464

Swipe Terminal ID9443C3002846

(registered to Dr. Byron Black)

Date of Transaction:1/15/14

Time of Transaction 10:06:23

Claim DetailsRecipient Name Mitchell Clark




Provider Name:

Byron Black, MD

Date of Service:1/15/14


Card Swipe Details- Provider Office or

Patient Home

Card Number: 5424176022824317


Plan ID# xxx-xx-6789

Prescriber ID# 0077464

Prescriber Name:

Richard Howard, MD

Rx Date: 8/1/13

Order Code: 11551

Claim Details Recipient Name Mitchell Clark




Provider Name:

Byron Black, MD

Date of Service:1/15/14

Outpatient matching adds the supplier match to the claim and the

provider/office match

Card Swipe Details- Supplier

Card Number: 5424176022824317


Plan ID# xxx-xx-6789

Supplier ID# 0088444

Supplier Name:

Flexmax Medical Supply, Trenton NJ

Date: 8/1/13

Order Code: 11551

Matching• Verifies outpatient visit

• Verifies location of visit

• Verifies provider and proper

location match

• Attests that physician order came

from physician office

• GPS location verification of home

care service

• Blocks order after fill


The transactions are usually immediately approved, denied or

referred for further information



3. Claim Matching

• Verify terminal code

• Verify medical merchant code

• Lost or stolen card?

• Previous time and location of swipe


4. Approve, Deny or Refer

At the:

• Merchant

• Provider

• Physician

• At home

1. Patient

swipes card



(via credit card network infrastructure)


When referred, the provider and/or the patient is contacted by the

insurance company before the transaction is approved



3. Claim Matching

• Verify terminal code

• Verify medical merchant code

• Lost or stolen card?

• Previous time and location of swipe


4. Approve, Deny or Refer

5. On referral, verify before taking

action

At the:

• Merchant

• Provider

• Physician

• At home

1. Patient

swipes card




Cost and Implementation Considerations

• Card Creation

– Castlestone creates/activates/deactivates and manages cards based on guidelines. Plan

Sponsor existing card manufacturing contracts can be used if they are compatible

• Hardware cost for plan & providers

– NONE. Uses existing credit card terminals

• Network costs for plan & providers

– NONE. Uses the existing credit card networks from provider offices for transactions

• Systems & programming costs

– S&P is very simple data exchange of new/change/delete clients or full real time integration

• Cost Structure

– Design and programming & card cost

– Hosting (data base & monthly hosting and management)

– Monthly per-member transaction fees


Typical Results

• Set up completely implemented in 60-75 days

• All technical milestones (transaction capture, claim matching, file and

interface implementation) exceed goals for speed and performance

• ROI for fraud prevention ranges from 125%-200% and can significantly

exceed this


Contact Us

Doug Brockway

Advance Consulting

(617) 834-0067

[email protected]

www.advancecons.com

CIO Advisory | Program Management | Business Development

How castlestone works

Healthcare

Transcript of How castlestone works