Provider Relations/Recruiting Services:
o Recruiting and provider contracting in support of the ongoing correctional healthcare operations. In the event that an existing provider ceases to perform services, or upon request from the client to provide additional specialty, or hospital services, JLSFE will recruit, and contract with a hospital or physician provider to fulfill the request or need.
o Single Patient Agreement Negotiations - When care at an out of network facility is required, JLSFE will negotiate on behalf of the client to secure a discount, whenever possible, for the services that are to be performed. The goal is to contract at terms that mirror the existing contract terms, but in the event that the provider is not willing to honor those terms, JLSFE will get the best possible deal available.
o Scheduling of Provider Appointments – JLSFE will be responsible for working with the provider or their designated staff directly in order to schedule appointments for inmates. JLSFE will take into consideration the special requests of the providers for specific days or hours of service that may be dedicated to seeing inmates. JLSFE will also handle the scheduling of providers that will go on-site to perform services at the correctional facility (CF).
o Credentialing – JLSFE will maintain up to date copies of the appropriate licenses and credentials that are required by the institution for providers that go on-site.
Institutional Based Services:
o Off-Site Service Request - JLSFE will schedule all off-site medical appointments for the client after the receipt of client’s approved Medical Service Request Form from the CF.
o Cancellations and Rescheduling - JLSFE will co-ordinate all requests for cancellations, or rescheduling of appointments upon notification from the client.
o Case Management – JLSFE will provide case management services for the CF to keep them apprised of the status of all inmates that may be in an inpatient status. JLSFE will provide information about the treatment being provided, estimated length of stay, estimates on additional care needed, and expected outcome. In the event that the JLSFE Case Manager identifies an alternate treatment that would lead to significant costs savings for the client, the Case Manager will recommend such treatment.
o Cost of Care Financial Estimates – JLSFE will provide an estimate on the cost of all off-site inpatient and outpatient medical care that will be provided under this contract. JLSFE will provide this estimate on its website within 48 hours of receipt of the Medical Service Request.
o Fund Control Management – JLSFE will provide the information required by the CF at the end of the fiscal year in order for them to close completed cases and will provides estimates on any remaining authorizations that are still in an open status.
o Verification of Care Authorization – JLSFE will verify that an appointment request was made by the CF for the inmate whose name appears on the claim.
o Fraud and Abuse Monitoring – JLSFE will verify that the codes that appear on the bill are proper, and include the proper use of all modifiers.
o Utilization Review – JLSFE will verify that services that were performed were the ones specified by the medical director at the CF, and that no unauthorized services were included.
o Medicare Compliance Checks – JLSFE will verify compliance with established Medicare billing regulations.
o Contract Compliance Checks – JLSFE will verify that the claim has been adjudicated in compliance with the contract terms that the provider and JLSFE have agreed to.
o JLSFE has Medicare billing experts that thoroughly review all claims that have been processed by the system. They manually review each batch in order to verify the accuracy of the adjudication process. At a minimum, the reviewer will check for:
Unbundling of Medical Services
Up-coding of Medical Procedures
Medical Necessity Review
o EOP Creation to Pay Provider – JLSFE will provide a detailed Explanation of Payment (EOP) to each provider for each and every claim received during the weekly billing period.
o Financial and Utilization Reporting – JLSFE will provide to client reports for managing the contract. JLSFE has multiple management reports currently available that are in use at other institutions, and will work with CF to develop specific reports upon request.
JLSFE is available by phone, M-F, 8:30 am-5:00 pm EST to handle customer calls. JLSFE will also provide all client personnel with contact information necessary to reach the Account Manager 24 hours a day, 7 days a week in the event of an emergency.
Overview of Services Available to Correctional Facilities