The document discusses strategies for increasing transparency and reducing costs in the healthcare industry. It notes that currently many healthcare plans operate as "black boxes" with little visibility into negotiation rates and fees. The document outlines an agenda to discuss improving transparency through cost-plus auditing of medical claims, analyzing performance audits of third-party administrators, and recovering overpayments from the past through more robust auditing. The goal is to help employers better understand how their healthcare dollars are being spent through greater access to data and contracts.
P&C Claims Automation Solution - A Competitive AdvantageParagon Solutions
Paragon Solutions, Inc.
Mike Cloutier – Vice President Insurance Markets
http://www.consultparagon.com/industries/insurance/property-and-casualty.html
ACORD Conference May 15-17, 2012
This document discusses captive insurance programs as a way for companies with large workers' compensation deductibles to effectively manage risk. It explains that captive insurance allows the company to take a tax deduction for premiums paid to the captive insurer, which can then set aside the premiums as tax-deductible reserves. The captive's reserves can be held as collateral by the primary insurance carrier above the deductible amount. The document also discusses measuring PEO performance, including analyzing medical cost savings from the insurance carrier's claims handling practices. Finally, it outlines best practices for loss prevention management, such as complying with safety requirements and conducting needs assessments for new clients.
From Complexity and Frustration to Simplicity and Effectiveness it is the most viable foundation for discovering new opportunities that build momentum and inspire growth.
This document provides guidelines for determining assurance levels for authentication of electronic government services in the Netherlands. It aims to standardize assurance levels across similar government services to improve transparency, accessibility, and legal protection for citizens and businesses. The guidelines classify services into assurance levels based on an assessment of the value at stake, considering criteria like legal requirements, the sensitivity of data exchanged, and economic or social impacts. The methodology assumes some services can be grouped into "families" with similar risks. The guidelines seek to support decision-making around appropriate authentication methods for different types of e-government services.
Today all organizations are subject to fraud risks. Large frauds have led to the downfall of entire organizations, massive investment losses, significant legal costs, incarceration of key individuals, and erosion of confidence in capital markets, Consequently as part of an organization’s governance structure, a fraud risk management program should be in place, including a written policy to convey the expectations of the board of directors and senior management regarding managing fraud risk.
Knowing present corporate focus and need for improved fraud risk governance & management, we’re pleased to launch our Fraud Risk Consulting services in addition to our existing bouquet of Risk advisory, Consulting, Training & Human Capital Services. Our services are offered through our multi location delivery centres in major metros with total presence in 11 Indian cities network.
Riskpro India Ventures provides integrated risk management consulting services to mid-large sized companies and financial institutions in India. It has offices in Mumbai, Delhi, and Bangalore, and alliances in other cities. Riskpro's services include fraud management, risk consulting, business ethics solutions, anti-corruption services, and forensics services. The company aims to provide quality advisory services at competitive prices using a hybrid delivery model and multi-skilled professionals with over 200 years of cumulative experience in risk management.
Riskpro India Ventures provides risk management consulting services through offices in major Indian cities. It aims to provide integrated risk management solutions to mid-large sized companies and financial institutions. Riskpro consists of experienced professionals with expertise in various industries. It offers services such as fraud investigations, risk management, business ethics programs, and forensic accounting. Clients include companies from sectors like banking, automotive, telecom, insurance, real estate, pharmaceuticals, energy, and securities.
Building Captive Program With Predictive Modelling Published Cayman Captive...paulmarshall
Predictive modelling tools provide captives with information to more accurately market, price, underwrite and defend claims without large investments of capital. These tools analyze vast amounts of data to detect changes in risk drivers and predict their impact. This insight allows captives to preemptively adjust premiums and risk management strategies. The tools also accelerate claims handling by providing context and focusing investigations. Overall, predictive modelling infuses more accuracy and efficiency into processes, lowering costs and creating competitive advantages for captives.
P&C Claims Automation Solution - A Competitive AdvantageParagon Solutions
Paragon Solutions, Inc.
Mike Cloutier – Vice President Insurance Markets
http://www.consultparagon.com/industries/insurance/property-and-casualty.html
ACORD Conference May 15-17, 2012
This document discusses captive insurance programs as a way for companies with large workers' compensation deductibles to effectively manage risk. It explains that captive insurance allows the company to take a tax deduction for premiums paid to the captive insurer, which can then set aside the premiums as tax-deductible reserves. The captive's reserves can be held as collateral by the primary insurance carrier above the deductible amount. The document also discusses measuring PEO performance, including analyzing medical cost savings from the insurance carrier's claims handling practices. Finally, it outlines best practices for loss prevention management, such as complying with safety requirements and conducting needs assessments for new clients.
From Complexity and Frustration to Simplicity and Effectiveness it is the most viable foundation for discovering new opportunities that build momentum and inspire growth.
This document provides guidelines for determining assurance levels for authentication of electronic government services in the Netherlands. It aims to standardize assurance levels across similar government services to improve transparency, accessibility, and legal protection for citizens and businesses. The guidelines classify services into assurance levels based on an assessment of the value at stake, considering criteria like legal requirements, the sensitivity of data exchanged, and economic or social impacts. The methodology assumes some services can be grouped into "families" with similar risks. The guidelines seek to support decision-making around appropriate authentication methods for different types of e-government services.
Today all organizations are subject to fraud risks. Large frauds have led to the downfall of entire organizations, massive investment losses, significant legal costs, incarceration of key individuals, and erosion of confidence in capital markets, Consequently as part of an organization’s governance structure, a fraud risk management program should be in place, including a written policy to convey the expectations of the board of directors and senior management regarding managing fraud risk.
Knowing present corporate focus and need for improved fraud risk governance & management, we’re pleased to launch our Fraud Risk Consulting services in addition to our existing bouquet of Risk advisory, Consulting, Training & Human Capital Services. Our services are offered through our multi location delivery centres in major metros with total presence in 11 Indian cities network.
Riskpro India Ventures provides integrated risk management consulting services to mid-large sized companies and financial institutions in India. It has offices in Mumbai, Delhi, and Bangalore, and alliances in other cities. Riskpro's services include fraud management, risk consulting, business ethics solutions, anti-corruption services, and forensics services. The company aims to provide quality advisory services at competitive prices using a hybrid delivery model and multi-skilled professionals with over 200 years of cumulative experience in risk management.
Riskpro India Ventures provides risk management consulting services through offices in major Indian cities. It aims to provide integrated risk management solutions to mid-large sized companies and financial institutions. Riskpro consists of experienced professionals with expertise in various industries. It offers services such as fraud investigations, risk management, business ethics programs, and forensic accounting. Clients include companies from sectors like banking, automotive, telecom, insurance, real estate, pharmaceuticals, energy, and securities.
Building Captive Program With Predictive Modelling Published Cayman Captive...paulmarshall
Predictive modelling tools provide captives with information to more accurately market, price, underwrite and defend claims without large investments of capital. These tools analyze vast amounts of data to detect changes in risk drivers and predict their impact. This insight allows captives to preemptively adjust premiums and risk management strategies. The tools also accelerate claims handling by providing context and focusing investigations. Overall, predictive modelling infuses more accuracy and efficiency into processes, lowering costs and creating competitive advantages for captives.
Riskpro India Ventures provides integrated risk management consulting services including fraud risk management. It has offices in major Indian cities and alliances in other cities, managed by experienced professionals. Riskpro aims to provide quality advisory services typically offered by large firms, but at more affordable prices than large firms. It focuses exclusively on risk management and has over 200 years of cumulative experience. Services include fraud investigations, anti-fraud programs, compliance, and forensic audits.
Riskpro India is a specialized Risk Management Consulting firm providing risk management advisory, risk trainings, internal audits, forensic accounting, investigations, fraud prevention, process reviews services etc.
Today all organizations are subject to fraud risks. Large frauds have led to the downfall of entire organizations, massive investment losses, significant legal costs, incarceration of key individuals, and erosion of confidence in capital markets, Consequently as part of an organization’s governance structure, a fraud risk management program should be in place, including a written policy to convey the expectations of the board of directors and senior management regarding managing fraud risk.
Knowing present corporate focus and need for improved fraud risk governance & management, we’re pleased to launch our Fraud Risk Consulting services in addition to our existing bouquet of Risk advisory, Consulting, Training & Human Capital Services. Our services are offered through our multi location delivery centres in major metros with total presence in 11 Indian cities network.
“We are quoted in recent Economic Times news as among fastest
Reid Hoffman, founder of LinkedIn, argues that services can reach millions of people unlike products. The article discusses healthcare services that use technology to monitor patients and alert caregivers to potential health issues. It also mentions other innovative services that lower healthcare costs and improve access through telemedicine or online appointment scheduling. Energy efficiency services that provide upgrades with no upfront costs and financing paid back from savings are highlighted as well.
Navigant Life Sciences Compliance Sunshine Act Article January 2012saul_helman
Life sciences companies that proactively communicate clear criteria for allocations and the management of reporting of various non-contrac¬tual expenses, as in the example of attendees who eat and attendees who choose not to eat at a dinner program, will be at a distinct advan¬tage in refining internal reporting mechanisms once the Final Rule is published
This document summarizes RSM Tenon's pension covenant advisory services. It discusses how most UK defined benefit pension schemes are in deficit, representing an involuntary creditor risk for companies. RSM Tenon helps trustees understand sponsors' ability to fund deficits and schemes, and helps sponsors navigate regulatory requirements during corporate events. The company provides independent covenant assessments involving sponsor financial reviews to help trustees and sponsors make informed decisions.
Retail Distribution Review: Preparing Insurance IT for Compliance and Strateg...Cognizant
The Retail Distribution Review offers a significant compliance challenge for UK insurers and advisors. CIOs must prepare by ensuring they have the right enabling technologies to support changing distribution strategies.
InsurTecSolutions provides insurtech and media products including underwriting and marketing services, an insurance premium estimator, insurance policy metrics, and news/information. It was founded by insurance executives to use content/analytics to help underwriters/brokers/insureds. The company offers 4 integrated products with little competition: underwriting/marketing programs, a premium estimator, a tool to compare policy values numerically, and industry news/services.
InsurTecSolutions was founded by insurance executives to provide insurtech products and services with little competition. They offer four integrated products: underwriting and marketing services, an insurance premium estimator, insurance policy metrics, and news/information. Insurance policy metrics provides a benchmark service that assigns insurance policies a numerical factor from 1 to 1000 based on claims simulations to compare coverage and value relative to premium. This allows easier comparison of different insurance policies.
Healthcare Risk Analytics Power Of Knowledge Us Captivepaulmarshall
The document discusses how using data analytics and predictive modeling (risk analytics) can help long-term care organizations better understand and manage their risks. It provides examples of how risk analytics can help identify facilities most at risk of claims, target risk management resources more effectively, and put claims in proper context. The document argues that incorporating risk analytics into risk management programs allows for more accurate and timely risk analysis with fewer surprises.
Credit scoring is a statistical technique used to evaluate credit risk by assigning a score based on a borrower's credit history and other data. It allows lenders to consistently evaluate large numbers of loan applications and distinguish higher and lower risk applicants. Statistical scoring models are more accurate and objective than judgment-based decisions. While credit scoring improves lending processes, concerns remain that some populations like minorities may be disadvantaged. Overall, credit scoring provides an effective way for lenders to balance risk and returns when granting loans.
Optimizing Revenue Cycle Management: Centricity Business at Saint Francis Hea...GE Healthcare - IT
For large hospitals and small provider practices alike, healthcare
reform and changing reimbursement models have introduced
significant new challenges to the business. It is now more important
than ever for organizations to have a well-designed revenue cycle
management (RCM) strategy in order to optimize their revenue cycle,
prepare for change, and maximize revenue. At the same time, mergers
and acquisitions among U.S. hospitals and physician practices add to
operational complexity, and with most hospitals employing a wide
vendor portfolio of HCIT solutions, these challenges further the
importance of running a tight financial enterprise. The inability to
effectively monitor and proactively manage the revenue cycle can
destroy profitability and make it difficult to focus on what matters
most — delivering outstanding care to patients.
8 expert tips for creating maximum efficiency in your underwriting workflow. Keep your underwriters focused on what they do best - evaluating risk and writing business.
The study found that late claim reporting significantly increases costs, with claims reported between 4-7 days costing 9% more on average, and claims reported over a month later costing 72% more. Specifically, late reported medical-only claims drove increased costs. Since the last study in 2007, timely claim reporting within 0-3 days improved from 57% to 64% of claims for the insurer's policyholders. The study emphasizes the importance of promptly reporting claims to reduce costs through early medical access and return-to-work programs.
Case Study - MetricStream offers a comprehensive GRC solution that addresses a wide range of health care regulations to reduce the overall cost of compliance management.
Cantor Health Interactive has acquired new healthcare management software to help businesses reduce costs. The software utilizes predictive modeling and simulation to identify unexpected medical and pharmaceutical expenses. It provides tools to monitor costs, understand cost drivers, and implement programs to educate employees and incentivize lower costs. For example, it can encourage switching to generics. Over 100 businesses tested the system, achieving average savings of over 15% on total healthcare costs.
How to Form and Operate a Network of Competing ProvidersPolsinelli PC
The Health Law Section of the Colorado Bar Association, together with the American Health Lawyers Association, hosted the 2nd Annual Colorado Health Law Symposium, a regional event co-sponsored by the nation's largest educational organization devoted to legal issues in the health industry. Mitchell Raup, Polsinelli Antitrust Shareholder presented How to Form and Operate a Network of Competing Providers at the symposium.
The document discusses the transition in healthcare from fee-for-service models to value-based and at-risk models where providers take on financial risk through capitated agreements. While these agreements provide upside, they also expose providers to downside risk from catastrophic claims. CMS requires stop loss protections be included in capitated agreements. The document recommends providers procure commercial stop loss reinsurance rather than relying on health plan coverage due to more defined terms, market competition, and access to ancillary services that can reduce claim costs. It introduces BKS-Partners, an insurance brokerage that specializes in architecting tailored stop loss programs through discovery, analysis, carrier negotiation, and ongoing services.
Using Advanced Analytics to Combat P&C Claims FraudCognizant
P&C insurers need to embrace predictive and advanced analytics -- as well as analytics as a service -- to combat the growing complexity and sophistication of claims fraud.
The document discusses the costs of achieving FedRAMP certification for cloud service providers (CSPs). It summarizes that:
1) Recent reports have cited costs of $4-5 million on average, but these were based on just a few CSPs and may not be accurate or representative.
2) The author's company, a FedRAMP third-party assessment organization, has seen costs more in the range of $150,000-$300,000 for advisory services and $150,000-$200,000 for assessments.
3) While certification requires significant resources, costs should not be prohibitive if the CSP plans efficiently and chooses experienced assessment partners. Not achieving certification could limit a CSP's
The document discusses the costs of achieving FedRAMP certification for cloud service providers (CSPs). It summarizes that:
1) Recent reports have cited costs of $4-5 million on average, but these were based on only a few CSPs and may not be accurate or representative.
2) The certification process through a third-party assessment organization (3PAO) like Veris Group typically costs $150,000-$200,000, with additional costs for advisory services, continuous monitoring, and annual recertification.
3) While certification is not cheap, when done efficiently it should not cost millions and is important for CSPs to gain federal contracts and comply with government security standards.
Claims Management - Edge through Efficiencyneetamundra
The document discusses improving the claims management process for insurance companies in India. It outlines issues with the current process such as high costs and poor customer satisfaction. An efficient claims system would use technology to streamline the process, reduce costs, speed up claims resolution, and improve customer satisfaction through features like automatic adjudication and fraud detection. Selecting a claims management system that meets requirements, is configurable, scalable, and supports standards would help insurance companies process claims more efficiently.
Riskpro India Ventures provides integrated risk management consulting services including fraud risk management. It has offices in major Indian cities and alliances in other cities, managed by experienced professionals. Riskpro aims to provide quality advisory services typically offered by large firms, but at more affordable prices than large firms. It focuses exclusively on risk management and has over 200 years of cumulative experience. Services include fraud investigations, anti-fraud programs, compliance, and forensic audits.
Riskpro India is a specialized Risk Management Consulting firm providing risk management advisory, risk trainings, internal audits, forensic accounting, investigations, fraud prevention, process reviews services etc.
Today all organizations are subject to fraud risks. Large frauds have led to the downfall of entire organizations, massive investment losses, significant legal costs, incarceration of key individuals, and erosion of confidence in capital markets, Consequently as part of an organization’s governance structure, a fraud risk management program should be in place, including a written policy to convey the expectations of the board of directors and senior management regarding managing fraud risk.
Knowing present corporate focus and need for improved fraud risk governance & management, we’re pleased to launch our Fraud Risk Consulting services in addition to our existing bouquet of Risk advisory, Consulting, Training & Human Capital Services. Our services are offered through our multi location delivery centres in major metros with total presence in 11 Indian cities network.
“We are quoted in recent Economic Times news as among fastest
Reid Hoffman, founder of LinkedIn, argues that services can reach millions of people unlike products. The article discusses healthcare services that use technology to monitor patients and alert caregivers to potential health issues. It also mentions other innovative services that lower healthcare costs and improve access through telemedicine or online appointment scheduling. Energy efficiency services that provide upgrades with no upfront costs and financing paid back from savings are highlighted as well.
Navigant Life Sciences Compliance Sunshine Act Article January 2012saul_helman
Life sciences companies that proactively communicate clear criteria for allocations and the management of reporting of various non-contrac¬tual expenses, as in the example of attendees who eat and attendees who choose not to eat at a dinner program, will be at a distinct advan¬tage in refining internal reporting mechanisms once the Final Rule is published
This document summarizes RSM Tenon's pension covenant advisory services. It discusses how most UK defined benefit pension schemes are in deficit, representing an involuntary creditor risk for companies. RSM Tenon helps trustees understand sponsors' ability to fund deficits and schemes, and helps sponsors navigate regulatory requirements during corporate events. The company provides independent covenant assessments involving sponsor financial reviews to help trustees and sponsors make informed decisions.
Retail Distribution Review: Preparing Insurance IT for Compliance and Strateg...Cognizant
The Retail Distribution Review offers a significant compliance challenge for UK insurers and advisors. CIOs must prepare by ensuring they have the right enabling technologies to support changing distribution strategies.
InsurTecSolutions provides insurtech and media products including underwriting and marketing services, an insurance premium estimator, insurance policy metrics, and news/information. It was founded by insurance executives to use content/analytics to help underwriters/brokers/insureds. The company offers 4 integrated products with little competition: underwriting/marketing programs, a premium estimator, a tool to compare policy values numerically, and industry news/services.
InsurTecSolutions was founded by insurance executives to provide insurtech products and services with little competition. They offer four integrated products: underwriting and marketing services, an insurance premium estimator, insurance policy metrics, and news/information. Insurance policy metrics provides a benchmark service that assigns insurance policies a numerical factor from 1 to 1000 based on claims simulations to compare coverage and value relative to premium. This allows easier comparison of different insurance policies.
Healthcare Risk Analytics Power Of Knowledge Us Captivepaulmarshall
The document discusses how using data analytics and predictive modeling (risk analytics) can help long-term care organizations better understand and manage their risks. It provides examples of how risk analytics can help identify facilities most at risk of claims, target risk management resources more effectively, and put claims in proper context. The document argues that incorporating risk analytics into risk management programs allows for more accurate and timely risk analysis with fewer surprises.
Credit scoring is a statistical technique used to evaluate credit risk by assigning a score based on a borrower's credit history and other data. It allows lenders to consistently evaluate large numbers of loan applications and distinguish higher and lower risk applicants. Statistical scoring models are more accurate and objective than judgment-based decisions. While credit scoring improves lending processes, concerns remain that some populations like minorities may be disadvantaged. Overall, credit scoring provides an effective way for lenders to balance risk and returns when granting loans.
Optimizing Revenue Cycle Management: Centricity Business at Saint Francis Hea...GE Healthcare - IT
For large hospitals and small provider practices alike, healthcare
reform and changing reimbursement models have introduced
significant new challenges to the business. It is now more important
than ever for organizations to have a well-designed revenue cycle
management (RCM) strategy in order to optimize their revenue cycle,
prepare for change, and maximize revenue. At the same time, mergers
and acquisitions among U.S. hospitals and physician practices add to
operational complexity, and with most hospitals employing a wide
vendor portfolio of HCIT solutions, these challenges further the
importance of running a tight financial enterprise. The inability to
effectively monitor and proactively manage the revenue cycle can
destroy profitability and make it difficult to focus on what matters
most — delivering outstanding care to patients.
8 expert tips for creating maximum efficiency in your underwriting workflow. Keep your underwriters focused on what they do best - evaluating risk and writing business.
The study found that late claim reporting significantly increases costs, with claims reported between 4-7 days costing 9% more on average, and claims reported over a month later costing 72% more. Specifically, late reported medical-only claims drove increased costs. Since the last study in 2007, timely claim reporting within 0-3 days improved from 57% to 64% of claims for the insurer's policyholders. The study emphasizes the importance of promptly reporting claims to reduce costs through early medical access and return-to-work programs.
Case Study - MetricStream offers a comprehensive GRC solution that addresses a wide range of health care regulations to reduce the overall cost of compliance management.
Cantor Health Interactive has acquired new healthcare management software to help businesses reduce costs. The software utilizes predictive modeling and simulation to identify unexpected medical and pharmaceutical expenses. It provides tools to monitor costs, understand cost drivers, and implement programs to educate employees and incentivize lower costs. For example, it can encourage switching to generics. Over 100 businesses tested the system, achieving average savings of over 15% on total healthcare costs.
How to Form and Operate a Network of Competing ProvidersPolsinelli PC
The Health Law Section of the Colorado Bar Association, together with the American Health Lawyers Association, hosted the 2nd Annual Colorado Health Law Symposium, a regional event co-sponsored by the nation's largest educational organization devoted to legal issues in the health industry. Mitchell Raup, Polsinelli Antitrust Shareholder presented How to Form and Operate a Network of Competing Providers at the symposium.
The document discusses the transition in healthcare from fee-for-service models to value-based and at-risk models where providers take on financial risk through capitated agreements. While these agreements provide upside, they also expose providers to downside risk from catastrophic claims. CMS requires stop loss protections be included in capitated agreements. The document recommends providers procure commercial stop loss reinsurance rather than relying on health plan coverage due to more defined terms, market competition, and access to ancillary services that can reduce claim costs. It introduces BKS-Partners, an insurance brokerage that specializes in architecting tailored stop loss programs through discovery, analysis, carrier negotiation, and ongoing services.
Using Advanced Analytics to Combat P&C Claims FraudCognizant
P&C insurers need to embrace predictive and advanced analytics -- as well as analytics as a service -- to combat the growing complexity and sophistication of claims fraud.
The document discusses the costs of achieving FedRAMP certification for cloud service providers (CSPs). It summarizes that:
1) Recent reports have cited costs of $4-5 million on average, but these were based on just a few CSPs and may not be accurate or representative.
2) The author's company, a FedRAMP third-party assessment organization, has seen costs more in the range of $150,000-$300,000 for advisory services and $150,000-$200,000 for assessments.
3) While certification requires significant resources, costs should not be prohibitive if the CSP plans efficiently and chooses experienced assessment partners. Not achieving certification could limit a CSP's
The document discusses the costs of achieving FedRAMP certification for cloud service providers (CSPs). It summarizes that:
1) Recent reports have cited costs of $4-5 million on average, but these were based on only a few CSPs and may not be accurate or representative.
2) The certification process through a third-party assessment organization (3PAO) like Veris Group typically costs $150,000-$200,000, with additional costs for advisory services, continuous monitoring, and annual recertification.
3) While certification is not cheap, when done efficiently it should not cost millions and is important for CSPs to gain federal contracts and comply with government security standards.
Claims Management - Edge through Efficiencyneetamundra
The document discusses improving the claims management process for insurance companies in India. It outlines issues with the current process such as high costs and poor customer satisfaction. An efficient claims system would use technology to streamline the process, reduce costs, speed up claims resolution, and improve customer satisfaction through features like automatic adjudication and fraud detection. Selecting a claims management system that meets requirements, is configurable, scalable, and supports standards would help insurance companies process claims more efficiently.
1. The insurance industry has principles of transparency but relationships between insurers and restoration contractors are often inconsistent and unclear.
2. Major issues include unclear pricing, ineffective processes, inexperienced adjusters, and personal relationships driving business over quality and capabilities.
3. Both parties need to better understand each other's needs and requirements to build a more transparent and consistent relationship focused on policyholders.
Direct to Employer - Dealing With Narrow Networks in the 'New Exchange World'McKonly & Asbury, LLP
This webinar was hosted by Tyler Wenger and Suzanne Sentman from McKonly & Asbury with special guest host Ernie Tsoules from Rhoads & Sinon.This presentation addressed the fact that self-insured employers are increasingly seeking to reduce employee health care costs. A new model of achieving this goal is taking hold in the market by employers contracting directly with new types of health care provider networks, commonly referred to as “narrow networks." This session explored the evolution of these new arrangements and its impact on employers, health care providers and employees. The session also addressed the key business and legal issues that are important to consider in developing these new relationships.
Check out our Upcoming Events page for news and updates on our future seminars and webinars at http://www.macpas.com/events/
The document outlines a framework for analyzing structural shifts resulting from the Patient Protection and Affordable Care Act (PPACA). It discusses three core themes - federalization, risk allocation, and value-driven integration - and how the law will lead to increased federal control, a reapportionment of wealth and risk, and a shift toward more coordinated, smart, and cost-effective models of care. Key changes include a tiered system of access, reordering of insurance markets, greater transparency, payment reforms, and a move from uniform procedures to personalized healthcare. The framework is meant to assess how these structural shifts will profoundly transform the US healthcare system over time.
Key Takeaways and Recommendations for Claims Software Adoption: DataGenixDataGenix
DataGenix claims software, fostering a more efficient, secure, and adaptable claims processing environment. The software's capabilities, combined with strategic implementation and ongoing optimization, position insurers to navigate the evolving landscape of healthcare and insurance with confidence and effectiveness.
3+ Keys to Proactive Underwriting (1).pdfCogitate.us
What is the advantage of insurance technology built by insurance
people? It has been designed with a passion to solve problems and meet your needs based on real-life experiences by people who have held your roles. Those who have done the job of producer, underwriter, product manager, CFO, and CIO, know firsthand the functions and features that impact speed to market and your ROI at a granular level. Welcome to
Cogitate and an introduction to future-ready underwriting on a modern
policy administration platform.
Cutting it costs and improving business performanceCAST
A Conversation with Kelly Cannon, former Vice President, Shared Application
Services at Kaiser Permanente, CIO, Enterprise Infrastructure at Nationwide
Insurance, and CIO at Wausau Insurance.
The document discusses the complexities of managing pharmaceutical rebate contracts and describes the features of AdvanceRebate, a software tool for modeling, managing, and optimizing rebate contracts. AdvanceRebate allows users to model rebate contract parameters, automatically build market baskets, compare contracts, generate projections and alerts, and facilitate tier swapping to maximize savings. The tool provides increased revenue, savings, transparency and streamlined workflow for managing the numerous intricacies of rebate contracts.
Milliman Datalytics-Defense® – Insurtech Innovation Award 2023The Digital Insurer
Milliman Datalytics-Defense is an analytics platform that analyzes defense cost invoices to uncover patterns and anomalies. This allows users to develop more cost-effective claims defense strategies by streamlining invoice review, flagging questionable charges, reducing costs, and discovering best practices. The platform provides benefits like extracting intelligence from invoices using advanced algorithms, improving efficiency in invoice management, identifying and implementing best practices across law firms, benchmarking performance against peers, and comparing actual results to predicted models. Case studies show clients have been able to decrease defense costs by $14 million per year after implementing insights from the platform.
The property and casualty insurance industry has seen declining profits in recent years due to lower investment returns and high claims costs. Fraud represents a significant portion of claims costs, estimated at $30 billion annually in the US alone. Predictive analytics can help insurers more efficiently identify fraudulent claims, recover costs through subrogation, optimize staff scheduling, and improve loss reserving. Early adopters of predictive analytics in claims processing are seeing returns of over 100% and improved customer retention compared to companies that have not adopted these techniques.
Smarter Contracting to Build Lasting Healthcare Payer-Provider Relationships.docSirion Labs
The success of a health insurance carrier is dependent on its selection of in-network medical professionals. But signing providers into a network is challenging. This blog will help you find out how a smart CLM solution can overcome this challenge.
The document discusses how blockchain can help overcome challenges in the insurance industry such as errors, fraud, lack of trust and complexity. It outlines issues like claims processing delays, customer onboarding difficulties, and lack of transparency. The summary then explains how blockchain solutions utilizing areas like smart contracts, distributed ledgers, and cryptography can streamline insurance processes, reduce costs and fraud, and increase trust and efficiency.
2. Agenda
Black Boxes and Beyond
1 Current Landscape
2 Navigant Report – North Carolina
✓ 3 ASO and Risk Management
4 Plan Design…wellness, telemedicine
5 Medical Concierge
6 Claims Recovery
7 Approach, Implementation and Timelines
3. The Current Landscape
Lack of Transparency
What if it became normative business practice for your payroll service
provider to set salary and wage increases and after years of near double digit
increases you request an audit and are told it’s their proprietary information
and really off limits to you, the employer?
Sound absurd?
It is, but this is the normative landscape for many
self-insured employer group health plans in
the country.
4. Transparency
Transparent Negotiations, Networks and Fees
insight – Expert Thinking From Milliman
“The lack of price information
stems from the confidential
Solutions for nature of negotiations between
the Future providers and payors.
Providers compete with each
other trying to get the highest
payment from payors, and
payors compete with each other
Transparency trying to set the lowest payments
to providers. In hopes of getting
the best deal, both providers and
payors want their
negotiated rates to be kept
Recovery from
confidential. Information is kept
the Past from the consumer that is
necessary to make the best
choices and drive an improved
market.” Will Fox, 2011
5. Performance Audit State Health Plan Risk Assessment
September 2011
“Although the Plan pays BCBSNC to access its provider network and
to benefit from its contracted discount rates with medical providers, all
contracts are between BCBSNC and its providers and are considered
proprietary information….Consequently, the plan is at risk for overpaying
claims because it must rely solely on BCBXNC auditors and information
from BCBSNC computer system to identify discount errors.”
Beth Woods, CPA, State Auditor
Plan Participant Totals 662,000 lives and equates to $2.8 Billion spend
6. Performance/Efficiency Audit
Navigant Consulting
Methodology =
Transparency
Standard
Business
Practice Flaws
Because of the test nature and other inherent
limitations of an audit, together with limitations of any
Minimal Fraud system of internal and management controls, this
Recovery Efforts audit would not necessarily disclose all performance
weaknesses or lack of compliance.
7. Performance/Efficiency Audit
Navigant Consulting
ASO ASO PBM
1 “The State Health Plan 2 “Specifically, the Plan does 3 “The State Health Plan’s
does not have policies not follow up on potential contract with Medco lacks
and procedures in place overpayments estimated by provisions that would
to mitigate certain risks Plan auditors, does not provide the SHP information
that could result in provide adequate oversight that is important to its
overpayments on member for its recovery audit oversight of contractor
medical claims.” function, has not taken performance. The contract
corrective action to does not require Medco to
eliminate or reduce provide information about
potential errors, and cannot the unit cost of
independently verify that the pharmaceuticals to the
Plan receives the proper State Health Plan. In
discount rate on medical addition, the current
claims.” contract with Medco does
t not allow the SHP to audit
the MAC list to determine
the competitiveness of
Medco’s pricing.”
Your own footer Your Logo
9. It’s Your Money
Your own sub headline
Welfare Benefit Plans
Two of every Three “health insurance” plans in the U.S. are “self insured plans”, meaning, there is NO
1 policy. The employer is the insurer.
Third Party Administrator
The TPA is merely a paperwork processor, an intermediary. ALL money paid for health claims is “Plan
2 money” supplied through the employers Welfare Benefit Plan.
.
Transparency is the KEY!
Therefore – any and all funds should have no “lock boxes” or “proprietary contracts” reducing the
3 efficiency of your health care plan!!!
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10. Can one cut costs and deliver better benefits?
•Risk Management – Structure Determines Function
Pure Risk vs. Speculative
Plan Design for optimal outcomes
CDHP
Wellness
Concierge
Telemedicine
•Risk Management
Infrastructure for optimal outcomes
Proprietary Networks
Cost Plus “You cut costs by
Real Time eliminating claims
or reducing the cost
per claim.”
Ron Dobervich
11. What Do Optimal Medical Outcomes at Lowest
Net Cost Really Mean?
In 2009, Our proprietary
net-work system’s clients
averaged a composite cost for
benefit plans 28.6% below the
Kaiser Foundation’s published
national average.
12. Cost Plus is Quantifiable: The numbers
tell the story….
Data driven diagram – Line diagram
$1,880,795 $1,130,134 41.33% $299,602 77.83%
377% Difference DO YOU THINK THIS WILL
AFFECT TREND?
13. Risk Management Done Right
Your data
Claim incurred. accessible in
real time.
Hospitals are
Subject to over paid more on
230 Proprietary average - all
Networks. while you save
money.
Hospital claims
Robust Case are subject
Management if
Needed. to COST
Plus audits.
14. Imagine owning your own data!
Data – unencumbered by ”proprietary” contracts....
Virtual OnSite: This is our Network
system’s name for its administrative
Cost Plus services product in which administrative
operations occur at the client’s worksite,
with client access to individual records
and reports via secure Internet access.
You will have access to information
regarding your health plan as if you
Real Time were administering the benefits on-site
Proprietary at your facilities.
Data Networks
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15. Plan Design
CDHP
With regard to first year cost savings, all
A qualified high deductible plan
1 coupled with an HSA or HRA can studies showed a favorable effect on cost the
equate to significant savings without first year of a CDH plan. CDH plan trends
sacrificing benefits. ranged from -4 percent to -15 percent.
Coupled with a control population on
Wellness traditional plans that experienced trends of +8
percent to +9 percent, the total savings
A standard based or participatory generated could be as much as 12 percent to
2 plan can incent healthy behavior.
20 percent in the first year. All studies used
some variation of normalization or control
groups to account for selection bias.
Tools to further efficiency
American Academy of Actuaries
A concierge service that shops cost
3 effective procedures and
telemedicine for consumer
convenience.
16. Transparency
Transparent Negotiations, Networks and Fees
insight – Expert Thinking From Milliman
“In no other area of our economy
do consumers receive services
Solutions for where they do not know the cost
the Future in advance and are
not able to make comparisons to
alternative suppliers. As a result,
healthcare provider costs have
Transparency remained immune
from the economic forces that
could control them. This
immunity has contributed to
greatly increasing provider costs,
Recovery from a major component in todays
the Past rising healthcare costs.”
Will Fox, 2011
17. Medical Concierge
A single procedure can have price variation of 500% or
more and facility charges ranging 1,000%.
So how do you know if your getting the best price?
YOU DON’T – “Blind by Design”
$291
717% $2,089
MAX RISK
395%
Difference
1
18. Recovery from the Past
Providers often pay large sums back to
Overpayments intermediaries. These payments in the provider
world are called “overpayments” or
“recoupments”.
Intermediaries have several, complex, often
Recoupments obscure, methods of receiving theses monies.
Our discussions with traditional audit firms
Who should demonstrate they are often not familiar with the
audit? provider claims nor ERISA regulations pertaining
to those claims and hence, are not aware of all
the sources of your refunded money.
19. Recovery from the past…
Who should audit your plan?
“The lack of follow-up will prevent the Plan from identifying and correcting the conditions that
allowed the overpayments to occur. Additionally, the Plan will fail to recapture a potentially
significant amount of overpayments.”
Beth Wood, CPA, State Auditor
In fact, a 2010 performance review by Navigant Consulting, Inc.
indicates that the Plan does not receive value for money on its fraud
recovery audit efforts. Navigant noted that fraud recovery efforts by
the Plan’s vendor, Blue Cross Blue Shield of North Carolina (BCBSNC),
do not meet industry standards.
“BCBSNC’s level of fraud recoveries for the SHP [State Health Plan] is
well below the industry average. For every $1 the SHP spent on fraud
and abuse detection, the SHP received only 10 cents in actual fraud recoveries.
Overall, the BCBSNC recovery dollars are equal to a little more than 1 percent of the SHP’s total medical
expenses, which is significantly below the industry average of 3 to 5 percent.”
20. Recovery from the past….
Federal Court Ruling
Self Insured Welfare Benefit Federal Court Ruled Against BCBSRI's
1 2 Overpayment Practice on October 27,
Plans have a fiduciary 2010 - Relied Upon U.S. Supreme Court
obligation to pursue these ERISA Rulings
funds.
The Court Ruled that BCBSRI’s Post-
Payment Overpayment Recoupment is a
Plan Fiduciary Conduct Governed by
Federal Law ERISA Instead of Provider
PPO Contract.
Subsequent Federal Court Rulings Give
Self-Insured Health Plans solid foundation
to proceed.
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21. Recovery from the past….
Claims Recovery Audit
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2005 2006 2007 2008 2009 2010
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25. Risk Management
Data driven diagram – Bar diagram
Cost Plus
Real Time Data
Proprietary Networks
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Plan Com
ARM Design CRC
pass
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Does the details of the network contract belong to your TPA/ASO or you, the self-insured plan sponsor?page 6, 3rd paragraph, Performance Audit State Health Plan Risk Assessment, September 2011
We establish preposition that current self-funded plans are built around two party contracts instead of three party.
Here we start with the first of our four major medical cost reduction initiatives. Three of the four take no cash outlays to implement and the fourth has a 10:1 ROI in year one. We believe that significant medical claims cost reduction can be achieved thru a system of total price transparency. These are significant cost reductions.
It produces results. This why we can do simple test. Let’s take your ten largest facility claims and let us do a heads up cost comparison.
To quote the NC auditor’s reports (you can have a copies if you would like), Page 9 (bottom half) thru page 10 of Navigant report beginning with “BCBSNC is not monitoring the quality…..Additionally; processes do not support full transparency to the State Health Plan regarding identification and recovery of claim dollars”. Pg. 29 shows no specificity to financial reporting. Middle paragraph states that data requirements are vague at best. First paragraph pg. 32 shows PBM lacks transparency. Page 44 (middle paragraphs) “BCBSNC” does not have “virtual data” capabilities!!
Our fourth service builds off of establishing the most efficient plan design. Plans we have taken over that have CDHP’s in place we have been able to get 5-15% greater efficiency in the reduction of total claims cost.
This is our price transparency/medical concierge service (10:1 ROI). These are the price range variations for the 8 facilities this MD has privileges at, the chart shows the total range of variation in the PPO system as a whole (717% WOW!!).