ASG Perspectives

Mental Health & Substance Use Disorder – Who’s Abusing Who?

Wednesday, July 27, 2016

by Sara Winand, RN, Director of Medical Management

The Mental Health Parity and Addiction Equity Act of 2008, which went into effect January 1, 2010 has changed the way Mental Health and Substance Use Disorders are viewed and paid by employer groups.

Cumulatively, a series of changes and trends have been having a serious impact on our mutual abilities to underwrite a competitive policy that works to support our employer groups’ businesses – not cripple their budgets.

The impact of Health Care Reform is extensive. The act mandates:

  • – No annual dollar limits
  • – No lifetime maximums
  • – No annual limits on number of days or visits
  • – Coverage extended to dependents up to age 26

We are now seeing covered individuals seek treatment for Substance Abuse more and more frequently, with costs for treatment ranging from $150,000 to $300,000 – for a single year.

In fact, in the six years since the Act passed, the group for which we’ve seen a growing trend in high claims is 16- to 26-year-olds! This age group is the highest risk category for relapse and ongoing charges, and has become a financial liability to plans and excess carriers across the U.S.

Why? Here are a few trends that may answer that question:

  • – Mental Health (which includes Substance Use Disorder) is now a covered benefit just like any other illness.
  • – Although many facilities have been out of network in the past, we are seeing a trend for now in-network claims for Substance Use.
  • – Facilities are now outsourcing labs, so urine drug screens are billed separately and frequently (many times daily) and often cost as much as the facilities’ daily charges.
  • – Facilities are billing incrementally, meaning these charges are flying under the radar and are not readily detected as a potential LARGE claim.
  • – Many plans only require precertification for inpatient acute care and can go unmonitored when the claimant steps down to Residential, Partial Hospitalization, IOP (Intensive Outpatient) then to OP.
  • – Facilities are typically located out of state; many resemble a resort: They are lined with palm trees, feature seascape landscaping, and offer 4-star cuisine, recreation and exercise programs which oftentimes include yoga, horseback riding, spa therapy, and more.
  • – Many websites feature logos of PPO networks but are not actually affiliated with these or any network.

As partners invested in protecting our employer groups’ interests, it’s important that we do what we can to stop the bleeding. Try asking the following questions when you see claims related to Mental Health or Substance Use Disorder treatment:

  • 1.Is this person’s treatment court-ordered?
  • 2.How is this treatment being certified for medical necessity?
  • 3.Is the facility licensed for the diagnosis and services it is billing for?
  • 4.Does the facility bill for IOP more than five days a week?
  • 5.Should I have claims and the medical records sent out for review before paying the claim and submitting to stop-loss? This is highly recommended.

With the lethal cocktail of health care reform, lack of financial limits, and mandatory coverage to age 26, it is anticipated that Mental Health and Substance Use Disorder claims will only become more prevalent.

Please contact us at info@asgrmi.com and let’s work together to try to reduce the financial risk these trends can pose to our employer groups.

 

Disclosure Process: An Important Underwriting Component

Friday, January 08, 2016
  • Having a proper Disclosure system in place is a benefit for all parties involved: the policy holder, the TPA/broker, and the carrier. An accurate and detailed picture of all known claimants or high-risk individuals allows us to reflect potential exposure in the final policy.

It is the quality of the claims information in the disclosure that impacts everything from the way the policy is structured (including the premium calculated) to how efficiently a claim will be handled.

The following are a few ins and outs of ASG Risk Management’s Disclosure process.

What is Disclosure?

A process of revealing the known claim risk of an employer at point of sale.

Why do we do it?

To evaluate the potential claim liability of an employer.

  • Prevent unexpected claim disputes or liability in the form of claim reductions or denials.
  • Provide a firm rate quote that is accurate and fair.

How do we do it?

Review of TPA/vendor-generated claim reports from a clinical perspective. This includes the following reports:

    1. – 50% reports
    2. – Rx reporting
    3. – Case Management reports
    4. – Pended claims report
    5. – Precertification report
    6. – Individual medical applications (if applicable)

Visit our Forms page to download commonly requested forms.

When do we do it?

  • 60 days prior to effective date.

When is the policy locked in?

  • Upon confirmation of coverage placement and completion of the items outlined above.

Please note: locking in after disclosure review may require updated reporting.

 

Be sure to ask your ASG rep for more specifics. We look forward to serving you and your clients!

 

 

Spotlight: The Diversified Group of Companies

Wednesday, December 02, 2015

For those of us in the risk management business, we know our work involves keeping up with the changing landscape of health insurance and employee wellness on a daily basis. Offering great customer service and encouraging an attitude of flexibility throughout our office are just a couple of variables that can mean the difference between being a good partner or a great partner.

That’s why we feel we’ve been so lucky to work with companies like Diversified Group of companies over the past 10 years. Based in Marlborough, Conn., this TPA firm is all about keeping up with the latest in employer health benefits while consistently delivering accurate and efficient benefits administration services.

When we were first introduced to Diversified, we immediately hit it off – after all, this is a company that invests its time professionally as well as personally, just like we do. Also like us, they take pride in being able to figure out a way to get what needs to be done, done – and always with a can-do attitude. (We like the idea of putting a smile in our voice, too!)

While Diversified Group has been administering self-insured health plans for more than 45 years, its three principals today are Brooks Goodison, Charlie Soleau, and Dan Sousier. Altogether, the company has a great track record for providing a very comprehensive and cost-effective approach to self-funded healthcare for businesses throughout the country.

In a recent conversation, Brooks noted that his company successfully accomplishes all this while competing in a fairly big pond. With competition from Blue Cross and Aetna to Cigna, Harvard Pilgrim and plenty of big names in-between, Diversified knows that if they’re not on their game, they’re going to be out.

So how to keep those big guns at bay? For Diversified Group, a critical differentiator is customer service – specifically, dedicated in-house teams focused 100% on service continuity. That sounds like a big commitment, but according to Brooks, Diversified Group is actually in a unique position to offer more flexibility and responsiveness than the larger companies because of its status as an independent company. With all customer service in-house, the firm can deliver a more cohesive, focused and experienced support tool and remain dedicated to working one-on-one with clients.

That level of personalization and dedication have paid off. Brooks notes the company has clients that have been with Diversified Group for more than 30 years, and average client retention is around 10 years. Its average employee group size is 110 employees, whereas the largest is 3,500 employees.

Plans for continued success won’t be slowing down any time soon, either. For example, a rapidly growing division of the Diversified Group is its Corporate Health & Fitness, which helps employers create worksite wellness programs such as one-on-one health screenings. This is an area where businesses are more and more frequently looking to actively manage the impact of healthcare costs on their P&Ls.

According to Brooks, one of the best ways to help ensure a positive outcome – financially for employers, and in terms of physical health for employees – is to keep the spotlight focused on health and wellness from within. He notes, “We believe heavily in worksite wellness and helping companies manage their health insurance costs. Know your cholesterol and physical numbers – and make sure the clients that are self-insured understand the limits of that risk.”

One trend that Brooks points to as becoming more prevalent today is helping companies manage the costs of specialty treatments new to the market. High-dollar infusion therapies, pharmacy claims and specialty drugs can cost upwards of $150,000 a year – and that cost could last as long as an employee’s life.

It’s a challenge for a business of any size, he concedes; but providing knowledgeable self-funding information and strategies to help clients budget for such costs – including the right stop loss controls – allows Diversified Group to help companies foster happy, healthier workforce groups while staying in control of their bottom lines.

If you’d like to learn more about Diversified Group, click here to visit the company’s website. 

 

Putting “Custom” in Employee Benefits

Wednesday, September 02, 2015

ASG Risk Management and Custom Design Benefits have an extensive history working together, and we continue to be thrilled with the value this trusted partner offers with every interaction.

Custom Design Benefits is a TPA based in Cincinnati, Ohio, offering tailored employee benefits administration services to employers throughout the U.S. Among the company’s portfolio of services is a wide range of self-funded health and wellness solutions.

As an MGU that prides itself on personalized solutions, we particularly like that Custom Design Benefits operates from the same tenets of creativity and integrity that align with our firm's values.

A Personal and Caring Approach

Custom Design Benefits’ president, Julie Mueller, is a shining star in our industry. With at least 30 years of experience in the TPA industry, she is personally dedicated to finding creative ways to contain costs for her clients. She has no fear! If she knows what’s right, she’ll go out and do it – which is likely why she and her firm are regularly recognized as national leaders.

This attitude becomes obvious when it comes to the company’s customer service – those “above and beyond” types of things, like making clients aware of what’s new and innovative… or the firm’s policy of personally meeting with every client on a regular basis. Plus, the team at Custom Design Benefits has multiple years of experience providing self-funded clients with services; they know what they’re doing.

With 55 employees and growing, it can be a challenge to maintain what the company calls an “extreme commitment to quality” – yet Custom Design Benefits sets the bar high and actually embraces the challenge.

Quality standards are in fact above industry standards for policies and procedures that people involved in the administration of benefits must follow. Operational metrics are monitored and measured continually – most recently resulting in 99.99% financial accuracy (meaning that every $100 an employer spends on its health plan is accountable to the penny).

Customization and Control

The company offers an interesting product that truly stands out from other TPAs in the marketplace. Its TrueCost Reference-Based-Pricing Plan is predictable and allows for a win-win-win scenario for all involved:

Employees have the flexibility to choose their provider as informed healthcare consumers, responsible for a co-pay only (no deductibles and no coinsurance).

Employers implementing this self-funded plan can reap significant savings and bring predictability to one of their most significant expense items

  • Providers are reimbursed fairly, consistently and in a very timely manner, eliminating the need to allocate precious resources toward accounts receivables and debt collection.

Custom Design Benefits also features direct contracts with local hospitals and independent physicians, giving employers a choice of hospitals. In turn, this structure gives the hospital the opportunity to do business directly with their clients – local employers – without having to go through the PPO network.

We are proud to partner with a company that sets high standards for plan management while continually making stop-loss insurance easy for employers to understand and use.

Interested in finding out more about this great partner? Visit www.customdesignbenefits.com or call 1-800-598-2929.

 

The Underwriters’ Perspective: The Building Blocks of a Strong Policy

Wednesday, June 10, 2015

By Sue Peebles, Underwriting Manager & Maggie Moynihan, Senior Marketing Underwriter

When it comes to underwriting a group of any size, there are many things that come into play, and a few key attributes are critical to success. Working together with a broker and/or TPA to meet the client’s needs, returning calls promptly, and consistently making due dates are just a few basics we keep in mind on a day to day basis. But a good foundation of knowledge and experience is essential when it comes to actually getting the job done.

A strong underwriter understands the importance of customer service, but additionally has complete understanding of group health insurance, ACA, managed care, HIPAA, and risk evaluation, along with the different roles played by TPAs, brokers, BUCAs, MGUs, and others. A lot of this experience comes from on the job training, and common sense should not be underestimated. The number of years someone has been underwriting also comes into play.

The ability to partner with a broker, TPA or consultant in a constructive manner is another key attribute developed over time. ASG is able to pride itself on these long-standing relationships that have been built. Our commitment to partnership has only become stronger over the years, as we continue to work closely with leading professionals who work from the same values.

Read more about Independent Insurance Marketing Executive Nancy Ferrell, a valued ASG partner for more than two decades. 

An important aspect to a strong underwriter is recognizing a good risk when it’s presented, combined with the willingness to go the extra mile in order to write the group. Taking the time to look over different options with the broker and/or TPA can be well worthwhile in the long run. Determining a common goal is the first step.

Working efficiently to get the job done and respond appropriately in a stressful, high volume environment comes with years of experience and again a strong foundation. Strong communication skills, also developed over time, are absolutely critical when it comes to developing partnerships and creatively closing business deals.

In addition to experience, what it really comes down to is integrity, honesty and transparency. These are the principles that ASG was founded on and that we continue to strive for in everything that we do.

Sue Peebles manages all underwriting, underwriter and support staff development, and RFP and renewal activity for ASG. With more than three decades of experience in group health insurance, she is an expert in the stop-loss field.

Maggie Moynihan works closely with our claims and marketing departments to evaluate employer stop-loss quotes while also building and maintaining relationships with brokers and TPAs. Maggie began her insurance career with ASG in June of 2006.

Meet the entire ASG team.

The Golden Rule Behind the Best Stop-Loss Policies

Monday, April 06, 2015

We’ve been noticing the word “integrity” being used in our industry:

“Integrity is at the core of every relationship.”

“We do business by adhering to the highest levels of integrity.”

And so on.

But what does that really mean, particularly within the context of a risk management company?

At ASG, we call ourselves “your stop-loss insurance partner” and for us, that phrase is so much more than a tagline—it’s about the relationships and the values that our business was founded on. It means the promises we make are the promises we keep. It’s in the people we hire and the level of service we deliver every day. It’s about the integrity that supports every relationship, new and old.

It’s a crucial cornerstone of our business, and has to be as solid as the granite rock our office’s foundation sits on.

For example, we all understand there are long-term implications to offering a quick sale. What happens when a carrier “buys business”—that is, offers a dirt-cheap premium then jacks up the rate the following year—is the complete opposite of working with integrity. It astonishes us that companies are willing to alienate their clients and undermine their credibility for a quick sale. In this business, referrals are everything and if we make our TPA or broker clients look bad, then it’s only the tip of the iceberg to making the entire industry look bad.

The exact opposite of working with integrity is failing to:

-Stand behind our product

-Offer personal customer service

-Support our partners’ businesses

You hear it all the time, but customer service really is the key to success. We’re proud that ASG has grown slowly and steadily, and we recognize we’ve been able to do that by committing to a few crucial best practices, all within the context of operating with integrity. We’ve learned that the best way to differentiate ourselves with TPA and broker clients is:

- Through the quality of the work we put out

- How responsive we are

- How accessible we are

It’s deceptively simple. Why ask you—an insurance professional operating in your local community—to put your reputation on the line and stand behind our product, without standing behind you? Why require you to make a million phone calls to resolve an issue, or wait 72 hours for someone to respond to your call? These practices and more only work to chip away at the integrity of our relationships and make life hard for everyone.

At ASG, we prefer to embrace the golden rule: Treat people the way they would like to be treated—with integrity!

From widget makers to retailers, consultants to salespeople, a lot of people lose sight of that guiding principle. We know that if we buy business, we lose business—so we just don’t. It hasn’t been through acquisitions or buying business that we’ve grown; it’s been by slowly establishing and valuing loyal, sustainable relationships. To us, that’s operating with integrity.

Welcome to ASG Perspectives

Monday, February 23, 2015

As our company continues to grow and evolve, our entire team of stop-loss medical insurance professionals is excited to kick off a new policy year with our updated website.

We hope you enjoy our fresh new look!

Click here to meet our team.

Whether you’re a TPA, Broker, Financial Consultant or Employer Client, be sure to watch this space for news, articles, and profiles of interest from the perspective of an established MGU.

In this space, we’ll bring you insights and perspectives into Underwriting, Claims, and many other aspects of a stop-loss policy. Plus, once a month we’ll spotlight a Partner or Client and provide you with an inside look into how we work as a team.

You’ll see a lot about commitment to service throughout this website—and that’s an important purpose of this blog because we actively work as a team on each and every policy, and strive to provide our partners and employer clients with the information they need to understand the complex world of risk management.

Click here to learn more about our approach to partner-based relationships.

We hope you’ll follow us on Twitter feed or look us up on LinkedIn and leave a comment.

Be sure to sign up for our monthly news roundup by entering your e-mail address in the form below.

And most importantly, we want to hear from you! What aspects of self-funded insurance would you like to learn more about?

 

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