ASG Perspectives

Lasers: Finding the Balance Between Risk and Reward

Wednesday, June 08, 2016

by Nathan Savage, Underwriter and April St. Cyr, Claims Manager

As we hear more and more people talking about stop-loss policies, the hot topic that keeps coming up seems to be lasers.

In its simplest form, a laser involves adjusting the stop-loss deductible for an individual who has a very high likelihood of exceeding the group’s regular individual specific deductible.

Lasers can present the group with additional liabilities – but as with any insurance, the coverage is for unknown risks, rather than known risks. There is also a cap that when hit, would start reimbursements. This allows a group to have a max cost, even on riskier members. (For example, we may have a laser of $250,000 for a cancer diagnosis but if the member’s claim goes over that amount, we still reimburse over the laser.)

Lasers can also be conditional, and are typically based on events such as transplants or chemotherapy. When this is the case, the covered member must meet the group’s specific deductible for anything that does not pertain to the condition set.

So when are lasers considered?

We start looking at members during the underwriting process. If there are obvious claimants who we predict will be over the group’s deductible, we make a note of it on our initial quotes.

Lasers are finalized when a group’s disclosure is signed and sent to us with supporting documents. The disclosure is an important tool that gives us an accurate and detailed picture of all known claimants or high-risk individuals. It’s also the last time that we look at the group to set lasers.

Click here to read more about the role disclosures play in the underwriting process.

Limiting exposure to all parties involved

When a notice is received on behalf of a high risk member, our Medical Management team reviews the notice using the following typical reporting:

– High claim reports

  • – Pended reports
  • – Pre-certification reports
  • – Case management reports

Based on the findings in these reports, we further research costs using web-based tools that provide critical information (such as clinical and financial analytics) and help with managing, reimbursing, and underwriting catastrophic claims.

Our team may also reach out to the TPA or case manager for any additional questions or information pertaining to the group in general, or the claim in particular.

And that’s not all.

ASG has established relationships with leading vendors who are willing to work with us, our TPA partners, and the employer group to secure deeper discounts for coverage of high-risk members.

Often, a medical bill review and audit company, or a medical cost containment and claims flow management organization, is able to negotiate with a provider and get sign-off on a rate that benefits all parties. Transplant networks for solid organ and bone marrow transplants offer excellent contracts to help mitigate the financial sting of complex care.

When Lasers Meet Claims

As we stated above, the laser is conditional and therefore specific to the covered individual. Following is a typical example.

Say Sue Smith’s policy includes a $150,000 conditional laser in the event of chemotherapy, and her employer group carries a $50,000 regular deductible.

If Sue undergoes a chemotherapy regimen and meets her laser of $150,000, our TPA partner would send in all required reporting for filing a claim as it would for anyone on the plan, regardless of a specific deductible. Our claims analyst would review and process the claim the same way as if there were no laser.

On the other hand, if Sue goes in for a knee replacement – which obviously is different than chemotherapy – and the knee replacement costs $70,000, we would simply reimburse the company the $20,000 difference over their deductible.

No matter the size of the policy or number of lasers included, what’s most important to an MGU like us is confirming that the claims:

  • – Are paid according to the plan document
  • – Meet all requirements of the stop-loss policy

At the end of the day, our goal is to write and stand by a policy that works for all parties involved.

We’re here to answer your questions about lasers. Contact us at any time! 

 

Spotlight on Bailey & Co. – All About Employee Benefits

Monday, June 06, 2016

When it comes to customer service – one of the most important metrics in our industry – we’ve benefitted from working with some of the most conscientious and caring TPAs and Brokers from all over the U.S.

Bailey & Company Benefits Group falls squarely into that category. As the Cincinnati, OH affiliate of one of the largest independent employee benefit consulting and management firms in the nation, Bailey & Company has figured out how to operate as a “boutique” firm while offering the capabilities and resources of large, multi-faceted enterprises.


The company’s goal is to help mid-sized businesses and publicly traded companies maximize the return on their employee benefits investments with an extensive list of personalized, consultative services.

Click to learn more about Bailey & Company’s areas of expertise

An Innovative Way to Work

The way they go about it is through a unique Account Management model that focuses on growth by referral.

We were curious, so we asked Bailey & Company’s Brenda Hoernschemeyer more about this refreshing approach.

She explained, “We view ourselves as an account retention organization: We are about integrating ourselves into the client. And to do that effectively you can’t have 60 clients and be involved with every client on the level we need to be.”

Instead, Bailey & Company’s Account Teams are comprised of benefit consultants, account executive and account managers. Each team maintains relationships with approximately 20 clients, rather than the typical 40-50.

Account Teams are responsible for every detail that has to do with each and every client – from marketing and customer service to negotiating the best rates and providing the customer support needed for a plan to be successful.

Exceeding Expectations Through Experience

The people managing Bailey & Co. clients know their stuff. As a company with a deep bench of tenured insurance pros, the firm prefers to hire only those with insurance or brokerage experience; very few exceptions are made, and only for motivated candidates who have demonstrated an interest and ability to learn.

Being able to stay on top of trends is equally critical, Brenda notes. For example, over the past few years, a big part of each team’s job has been to help clients navigate their way through audits – primarily related to HIPAA, but often ERISA.

Keeping up with regulations such as these and the many moving parts of the self-funded insurance world could be more of a challenge, she says, if not for the fact that “I read, read, read – everything, every day.”

Additionally, working with “honest and trustworthy” partner MGUs like ASG makes her job meeting client needs that much easier. “I call ASG because it’s a good, honest relationship,” she says. “It’s just respectful, and they always understand why I have to ask the questions I do.”

We love hearing reviews like this and appreciate our positive relationship with Bailey & Company. If you’re interested in working with an experienced MGU that offers personalized service, drop us a line!

For more information about Bailey & Company, visit www.baileyandco.com.

 

 

Innovative Products. Personalized Services.

Solutions for YOUR Business.

Let’s talk about protecting your clients’ self-funded health plans.

 

Submitting Form...

The server encountered an error.

 

Captcha Image

Submitting Form...

The server encountered an error.

 

©2016 ASG Risk Management, Inc. All Rights Reserved. Privacy Policy. Site Map. Website by www.atompie.com