Tailored Third Party Administration

The National Institute of Occupational Safety and Health’s World Trade Center Health Program Supports Responders and Survivors of the September 11, 2001, Attacks

The World Trade Center (WTC) Health Program administers medical and pharmacy benefits to eligible responders and survivors of the September 11, 2001, WTC attacks. In 2016, The National Institute of Occupational Safety and Health (NIOSH) hired Karna, LLC, to operate and evolve the Program’s administrative services.

CHALLENGE
STRATEGY & SOLUTION
Results

Challenge

Operating a limited benefit health plan requires specialized knowledge and expertise. 

In 2011, the Centers for Disease Control and Prevention’s NIOSH established the WTC Health Program, a limited benefit health plan, to administer medical and pharmacy benefits to eligible responders and survivors of the September 11, 2001, attacks on the WTC, the Pentagon, and in Shanksville, Pennsylvania. During the initial 5-year period of establishing the WTC Health Program, NIOSH’s support services were built on custom, dedicated information technology platforms. 

In 2016, NIOSH needed assistance with operating and evolving the WTC Health Program. It awarded Karna, LLC, a CPFF prime contract for Third Party Administrator (TPA) services. The contract included management of the program, data, and operations systems, as well as labor support across member services, provider network, medical management, and claims adjudication.

The WTC Health Program has helped thousands of responders, and residents and workers recover their health following the 9/11 attacks. Video courtesy of NIOSH.

Strategy & Solutions

A holistic approach to better serve WTC Health Program members

Our first step was to assess and analyze the existing infrastructure and lay out a plan for managing the program moving forward to better serve the members. Karna employs a continuous improvement methodology to evolve WTC Health Program systems and services toward federal health program and commercial TPA best practices. 

As part of our overall solution, we manage and staff member services systems to process member enrollment applications and medical condition certification requests. This work supports NIOSH determinations of beneficiary enrollment and benefit plan eligibility based on an individual’s exposures during and following the September 11, 2001, attacks.

We continue to develop and manage the program’s network of participating providers who perform screening, diagnostic, and treatment services to the member population in the greater New York metropolitan area. To keep the providers current, we train and support providers in new WTC Health Program policies and procedures, including coverage determinations, medical coding, and claims submissions. 

Our medical management team provides recommendations for health plan policy, codebook management services, and medical claims review services. 

Additionally, we provide systems infrastructure, services, and staff to support receipt, adjudication, and reconciliation of medical claims. 

We also host and maintain the claims infrastructure, as well as provide centralized call center and mailroom services to support the Program. Our claims processing services include fraud waste and abuse, medical and pharmacy claims payment, and secure information maintenance and exchange. 

We work hand in hand with our sister Celerian Group company, Palmetto GBA, to ensure all processes work across the various services we provide. Karna and Palmetto GBA implemented a streamlined solution to enroll providers based on Medicare enrollment requirements and created a WTC Health Program web portal for prospective providers to register with the Program, and to review and agree to the Program’s terms and conditions.

Strategy & Solutions

A holistic approach to better serve WTC Health Program members

Our first step was to assess and analyze the existing infrastructure and lay out a plan for managing the program moving forward to better serve the members. Karna employs a continuous improvement methodology to evolve WTC Health Program systems and services toward federal health program and commercial TPA best practices. 

As part of our overall solution, we manage and staff member services systems to process member enrollment applications and medical condition certification requests. This work supports NIOSH determinations of beneficiary enrollment and benefit plan eligibility based on an individual’s exposures during and following the September 11, 2001, attacks.

We continue to develop and manage the program’s network of participating providers who perform screening, diagnostic, and treatment services to the member population in the greater New York metropolitan area. To keep the providers current, we train and support providers in new WTC Health Program policies and procedures, including coverage determinations, medical coding, and claims submissions. 

Our medical management team provides recommendations for health plan policy, codebook management services, and medical claims review services. 

Additionally, we provide systems infrastructure, services, and staff to support receipt, adjudication, and reconciliation of medical claims. 

We also host and maintain the claims infrastructure, as well as provide centralized call center and mailroom services to support the Program. Our claims processing services include fraud waste and abuse, medical and pharmacy claims payment, and secure information maintenance and exchange. 

We work hand in hand with our sister Celerian Group company, Palmetto GBA, to ensure all processes work across the various services we provide. Karna and Palmetto GBA implemented a streamlined solution to enroll providers based on Medicare enrollment requirements and created a WTC Health Program web portal for prospective providers to register with the Program, and to review and agree to the Program’s terms and conditions.

Results

Continuous monitoring and improvement ensures effective and efficient services to members

Since 2016, we have made improvements in terms of system and process standardization, data collection and IT infrastructure, IT integration and interoperability, and cybersecurity.  

The WTC Health Program data is received from a variety of sources, including federal, public, and private systems. We provide continuous improvement and updates to ensure that the systems are working together effectively and efficiently. We also initiate updates to ensure data security. We maintain a consolidated data warehouse that supports reporting and provides detailed analysis of operations and healthcare delivery. 

In terms of claims, the claims processing system is made up of a disparate set of solutions and data sources, both internal and external. We routinely analyze, measure, improve, and optimize business processes to evolve with these systems and ensure that claims are processed as quickly and accurately as possible.

Finally, we provide recommendations and implement improvements to protect the systems and data involved within the WTC Health Program IT ecosystem and to ensure information exchange systems are HIPAA- and FISMA-compliant. We have developed security and continuity plans that outline procedures for execution in case of a cybersecurity emergency. Additionally, our fraud waste and abuse compliance plan incorporates cybersecurity practices such as automated analysis of data collected.

Results

Continuous monitoring and improvement ensures effective and efficient services to members

Since 2016, we have made improvements in terms of system and process standardization, data collection and IT infrastructure, IT integration and interoperability, and cybersecurity.  

The WTC Health Program data is received from a variety of sources, including federal, public, and private systems. We provide continuous improvement and updates to ensure that the systems are working together effectively and efficiently. We also initiate updates to ensure data security. We maintain a consolidated data warehouse that supports reporting and provides detailed analysis of operations and healthcare delivery. 

In terms of claims, the claims processing system is made up of a disparate set of solutions and data sources, both internal and external. We routinely analyze, measure, improve, and optimize business processes to evolve with these systems and ensure that claims are processed as quickly and accurately as possible.

Finally, we provide recommendations and implement improvements to protect the systems and data involved within the WTC Health Program IT ecosystem and to ensure information exchange systems are HIPAA- and FISMA-compliant. We have developed security and continuity plans that outline procedures for execution in case of a cybersecurity emergency. Additionally, our fraud waste and abuse compliance plan incorporates cybersecurity practices such as automated analysis of data collected.

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