1. TRICARE Global Remote Overseas Contract- Review 2007-2008 International SOS Medical Director TRICARE Pacific 23 rd October 2008

2. TRICARE Pacific 2 Topics Who is International SOS (Intl.SOS) TRICARE Global Remote Overseas (TGRO) Intl.SOS TRICARE Network Collaborative Case Management Quality Reviews Challenges in Korea and Japan

3. TRICARE Pacific 3 INTERNATIONAL SOS Introduction to

4. Worldwide reach Human touch Over 20 years experience 5,600+ employees worldwide Medical, security, aviation, and technical specialists on staff –1800 (32%) are medical professional –Multi-lingual staff with 70+ languages and dialects spoken Global Network of 51,000+ credentialed providers Experts in each center managing and auditing a global network of medical correspondents and hospitals 7,650 clients worldwide – 83% Fortune 100 Experience and Expertise

5. Worldwide reach Human touch INTERNATIONAL SOS WORLDWIDE

6. Worldwide reach Human touch Services Global Emergency Assistance Remote Site Medical Services Health Care Management Security services International Clinics Specialized assistance services Online services

7. Worldwide reach Human touch Global Medical Assistance 24-hour worldwide information and assistance Pre-trip information and advice Doctor/hospital referrals Medical monitoring and case management Emergency evacuations/repatriations Dispatch of doctors or specialists Hospital deposit guarantees Repatriation of mortal remains Integration with security crisis centers

8. Worldwide reach Human touch Global Medical Services: Remote Site Medical Services Site surveys and audits Development, operation and management of medical facilities Selection and training of medical staff Procurement of medicines/supplies First aid training Continuing education for medical professionals Health assessments Community health programs Emergency and disaster planning Occupational health programs

9. Worldwide reach Human touch International Clinics 28 clinics worldwide International standards of care in developing areas High level of family practice medicine and emergency care International health care professionals Well-trained local medical staff 24-hr emergency assistance In-house laboratory/diagnostics/pharmacy

10. Worldwide reach Human touch Alarm Centers 26 worldwide Open 24 hours a day, everyday Multi-lingual operations coordinators Full-time doctors, nurses and pharmacists Global network of preferred medical, legal and security providers Over 70 languages and dialects spoken Online airline and hotel reservation systems

11. Worldwide reach Human touch Aviation Resources Ten dedicated air ambulances strategically located around the globe State-of-the art intensive care transport system 24/7/365 access to private and commercial aircraft In-house physicians trained in aeromedicine Global aviation department to secure flight paths and clearances Worldwide network of escort doctors and nurses

12. Worldwide reach Human touch Options for transport are varied…

13. Worldwide reach Human touch

14. TRICARE Pacific 14

15. TRICARE Pacific 15 COMMERCIAL AIR

16. TRICARE Pacific 16

17. TRICARE Pacific 17 TRICARE GLOBAL REMOTE OVERSEAS (TGRO)

18. TRICARE Pacific 18 Cashless / Claimless Services to TGRO Beneficiaries Case Management – Quality of Care Global Consistency of Approach in Delivering Healthcare Services SOS TRICARE Credentialed Network Outpatient, Inpatient, and Specialist Care 24 x 7 Urgent/Emergent Care Capacities Medical Transports Governed by TRICARE Policies TGRO AD/ADFM Beneficiary Services

19. TRICARE Pacific 19  Coverage under TGRO  Routine, Urgent and Emergent Care for Active Duty (AD) and Active Duty Family Members (ADFM) permanently stationed in a TGRO Location.  Urgent and Emergent Care for Active Duty TDY/TAD, Reservist, On Leave, Liberty, Navy/Marine/Coast Guard Deployed.  Urgent and Emergent Care for AD traveling in MTF Countries (NEW)  Emergent Care for PRIME ADFM traveling OCONUS (NEW)  TRICARE Beneficiaries Excluded from TGRO  TRICARE Retirees / TRICARE For Life  TRICARE Standard  Direct Care  Coverage under TGRO  Routine, Urgent and Emergent Care for Active Duty (AD) and Active Duty Family Members (ADFM) permanently stationed in a TGRO Location.  Urgent and Emergent Care for Active Duty TDY/TAD, Reservist, On Leave, Liberty, Navy/Marine/Coast Guard Deployed.  Urgent and Emergent Care for AD traveling in MTF Countries (NEW)  Emergent Care for PRIME ADFM traveling OCONUS (NEW)  TRICARE Beneficiaries Excluded from TGRO  TRICARE Retirees / TRICARE For Life  TRICARE Standard  Direct Care TRICARE Global Remote Overseas

20. TRICARE Pacific 20 Intl.SOS TRICARE History

21. TRICARE Pacific 21 TRICARE Global Remote Overseas Credentialed Network SOS TRICARE Credentialed Network Primary and specialist care Monitoring and quality control Distributed Provider Relationship Management Leverages utilization by other Intl.SOS Corporate, Government, and Insurance clients Beneficiaries Enrolled and TDY/TAD/Deployed 24x7 medical advice from Intl.SOS doctors/nurses Single Service Standard Across Regions Europe Latin America Asia Pacific Claims Processing ICD/CPT Standard Coding Translation of International claims HIPAA Compliance International SOS Claims Audits Case Management / Medical Oversight Management of Routine and Urgent Care consistent with TRICARE Healthcare Policies Case management system that provides a longitudinal record of interactions with beneficiary Referral Management into MTFs and private sector

22. TRICARE Pacific 22 INTL.SOS TRICARE NETWORK

23. TRICARE Pacific 23  Network Management staff located in SOS Alarm Centers globally  Manages an extensive world-wide service provider network  Ensures providers adhere to SOS quality standards through regular site visits, audits, and credential verification  Provides customized network solutions in accordance with client objectives  SPIN : A proprietary worldwide information system to classify and manage providers  SPIN : S ervice P rovider I nformation N etwork International SOS Global Assistance Network

24. TRICARE Pacific 24 TRICARE Global Remote Overseas Locations 145 Countries 240Locations Multiple Locations Intl SOS TRICARE Regional Center

25. TRICARE Pacific 25 The Tricare Network

26. TRICARE Pacific 26 Network Challenges Clear distinction between the fully credentialed Intl. SOS Tricare network & the outer rings Monitoring healthcare in host nation facilities Recognizing the ‘gulf’ between East-West medical training & practice Host nation healthcare vs MTF’s Low threshold for medical transport

27. TRICARE Pacific 27 Managing a Global Network  Network is determined by many factors  The network is managed through continuous monitoring of credentials, customer feedback, concurrent case management, site visits  Selecting the Most Appropriate Providers  Sizing the Network to manage quality and utilization  Knowing and Communicating the Limitations of the Network  Country/Location Specific

28. TRICARE Pacific 28 TGRO Credential Requirements  Confirmed current Medical/Dental registration  Copy of a current C.V. with 5 year history  Primary source verification of Medical/Dental training at a recognized facility  Copy of signed service provider agreement  Copy of site visit report  Confirmation of Malpractice insurance, where applicable

29. TRICARE Pacific 29 Credentialing Process  Other Credentialing Aspects  English speaking  Accepts SOS GOPs or signed agreement  US Board Certification  Leveraging of hospital credentialing procedures  Experience with International Patients

30. TRICARE Pacific 30 SOS TRICARE Network Maintenance Activities  Provider Data Maintenance  Provider information entered in SPIN  Immediately available to Operations  WPS Provider ID  Banking details / Preferred payment methods  Hard copy files as back-up  Provider Communication  Operations, POC and Member Feedback  Direct Communication or Beneficiary Satisfaction Surveys  Investigation and Resolution of Provider/Beneficiary Issues

31. TRICARE Pacific 31 Building Relationships Relationship building with host nation providers  targeted at all levels  Physician, Nursing, Reception, Cashier Guarantees of Payment (GOP) A network is only as good as the last time it was used and paid. Three Intl.SOS elements involved 1. Global Area Network personnel ( agreement ) 2. Multi lingual coordinators ( send the GOP) 3. Accounts & billing staff ( receive/pay invoices)

32. TRICARE Pacific 32 COLLABORATIVE CASE MANAGEMENT

33. TRICARE Pacific 33 Case Management services Based in International SOS Alarm Centers with a dedicated TRICARE team First contact Coordinators and Nurses Supported by other SOS Medical staff and International SOS Centers 24/7 service including verification of eligibility through GIQD Direct access to services in over 70 languages

34. TRICARE Pacific 34 Medical Oversight The Notification Of Case ( NOC) A requirement to advise to TAO-P Medical Director, as part of medical oversight & monitoring of care of -all admissions -hospitalizations extending over a 1 week -readmission for same diagnosis within 30 days -4 x spec. visits < month for same diagnosis - outpatient costs >$2000 /month - limits on Mental Health/Physical Therapy visits

35. TRICARE Pacific 35 QUALITY MANAGEMENT

36. TRICARE Pacific 36 Quality Management Ensuring an International Standard of Care TRICARE Quality Plan  Quality Issue Review Process  Grievances, Potential Quality Incidents (PQI), and Quality Incident (QI)  Escalation process within Intl.SOS  Escalation to TRICARE Area Office on all Quality Incidents  Network Credentialing Requirements  TRICARE Bi-Annual Audits  Beneficiary and TRICARE POC Surveys

37. TRICARE Pacific 37 Quality Management (cont) Network TRICARE Provider Credentialing Provider agreements Site visits Right Sizing Beneficiary demographics Case Management Concurrent Case Management Longitudinal View Medical Oversight TAO Escalation CAD Oversight Review of medical reports and discharge summaries Quality Case Reviews TRICARE Bi-Annual Audits Beneficiary Surveys Communication with other Govt Agencies (e.g. Health Unit) Utilization Review Claim reviews Chronic Case Reviews Utilization Management Reviews >$5,000 Individual >$10,000 Family Visit thresholds for same diagnosis

38. TRICARE Pacific 38 Beneficiary Surveys Tools  Automated delivery from Intl SOS Case Management System  Pushed to the Beneficiary through the email & Web  Surveys Results Collected by Third Party – KeySurvey  Beneficiary Survey Reports are deliverable every (6) months to TMA

39. TRICARE Pacific 39 CHALLENGES IN KOREA & JAPAN

40. TRICARE Pacific 40 Big Challenges require great effort and coordination… Healthcare in Japan & Korea

41. TRICARE Pacific 41 Healthcare in Japan & Korea National Health Insurance Hospitals & clinics are national health system centric Limited English language capability Private organizations have limited influence ER’s are crowded & capability can be limited Public ambulances move only within their district Ambulances have limited capability Reluctance to accept guarantees of payment

42. TRICARE Pacific 42 A recommendation for host nation in-patient care for non urgent surgery depends upon a number of factors; Standard of care available? Requirements of the Services  Fitness for Duty  Length of absence from duty and impact on the unit  Need for & duration of Rehab  VA issues Financial estimates Comfort level of the patient Healthcare in Host Nations Japan & Korea

43. TRICARE Pacific 43 Intl.SOS Example International SOS Seoul  Established in 1989  Leading provider of medical and security assistance in the region  Business and Leisure Travelers  Corporate Expatriate communities in South Korea  Seoul receives over 4 Million tourists per year  1.2 million are covered under Intl.SOS

44. TRICARE Pacific 44 Intl.SOS South Korea Volumes drive Intl.SOS capabilities to engage providers.  Map shows were Intl.SOS have agreements and financial arrangements for healthcare services Intl.SOS Local Operations Staff and Medical team are crucial in obtaining the appropriate and International Standard of care

45. TRICARE Pacific 45 QUESTIONS?