Overview

Medicare Part D prescription drug plan costs and coverage usually change each year resulting in significant membership volatility as seniors and other beneficiaries seek the most appropriate mix of cost and coverage. This volatility, which comes to bear during the Annual Election Period (AEP), results in the need for scalable, agile and reliable processes and technology specifically designed to handle the sudden spikes in volume and the complex requirements of government regulation, compliance and oversight.

In addition, demographic trends show the emergence of an aging population that expects, even demands, ever-increasing levels of benefits and service. This factor adds to the pressure to respond to members in an effective, efficient and knowledgeable manner in order to retain or expand market share.

TMG Health is the largest and most experienced BPO vendor serving the managed Medicare, Part D and PDP market segments. The company offers a broad solution set supporting dozens of health plans and serving more than 2.8 million members in all 50 states. Our clients range from large, multi-state or national plans with hundreds of thousands of members to small, regional plans with less than 2,000 members.

TMG Health supports over 1.5 million Part D members. The company has performed CMS data file interface and Eligibility Reconciliation for nearly ten years and has administered Part D plans since their inception in 2006. TMG Health clients, including both PBMs and health plans with Part D, have earned excellent ratings under CMS' 5 star system.

With 10+ years of operational success in the government health plan sector, TMG Health is uniquely suited to serve the needs of insurance plans in the PDP and MA-PD market.

TMG Health offers:

  • Deep understanding and expertise in government health plan administration and compliance
  • Customized technology and processes designed for efficiency in government health plan administration
  • Scalable systems and personnel resources
  • Highly secure operating environment
  • Cost-effective alternatives to in-house operations

 

TMG Health offers a complete set of outsourcing services for Part D administration delivered in a cost-effective and compliant manner designed to protect and enhance plan performance and brand value.

Part D Services provided include:

  • Enrollment processing through IEP and AEP
  • Disenrollment processing
  • Coordination of benefits
  • Member and provider calls
  • Part D COB letters
  • Premium Billing
  • Fulfillment services:
    • QC Fulfillment Extracts & Print Material
    • Member Material Readiness
    • Production Planning
    • Management of Mailings

 

PDP Enrollment Processes include:

  • Real Time CMS Eligibility
  • Validation Rules Engine
  • Electronic /Paper File Load
  • Eligibility Discrepancy Reporting
  • Record Maintenance/Correction
  • Auto Enrollment System Update
  • Transaction Reporting

 

Part D Customer Service includes:

  • Extended hours of operation during AEP per CMS/client guidelines
  • Process, Receive, Determine Best Available Evidence for members with Low Income Subsidy
  • Process & Handle Client's Returned Mail
  • Benefit Inquiry Calls
  • Outbound Education Verification Calls
  • Agent/Broker Calls
  • Document, Track, & Report Threatened Legal Actions occurrences
  • Document, Track, & Report Inadvertent HIPAA occurrences
  • Document, Track, & Report Fraud, Waste, Abuse occurrences
  • Telephonic Declaration of Prior Prescription Drug Coverage.

 

TMG Health has been named the number one provider of BPO services to the government healthcare market for the past three years based on client feedback.