MANAGED CARE

STOP-LOSS SPECIALIST

Specific Stop-Loss

Protects medical groups, IPAs, PACE providers, & other capitated entities against catastrophic expenditures incurred by managed care patients.

Aggregate Excess of Loss

Reinsurance provides ACOs a safety net for attributed benchmark revenue under traditional Medicare risk arrangements with CMS.

HMO Reinsurance

Protects Medicare Advantage, Managed Medicaid and Commercial HMO health plans against excessive claims by limiting catastrophic claims.

Bundled Payment

Targets excess costs for specific procedures and episodes of care under CMS or commercial payor bundled payment models.

Surety Bonds

Helps ACOs to satisfy CMS’s
capital requirements and
repayment guarantees.

PINNACLE BROKERS

Pinnacle Brokers Insurance Solutions, LLC is a leading insurance brokerage that provides reinsurance and risk management solutions to Manged Care Organizations.

MANAGED CARE SUPPORT

UNIQUE RISKS Capitation and value-based payment models present unique risks for Managed Care Organizations. Medicare Advantage, Managed Medicaid, and commercial HMO plans increasingly link financial incentives and reimbursement rates to the quality of patient health outcomes. Similarly, CMS is incentivizing ACOs to share more risk tied to outcomes for fee-for-service Medicare beneficiaries.

Review client’s HMO/CMS risk contracts, financial burdens
and membership cohorts.

Evaluate enterprise-level financial profile and risk mitigation program.

Collect claims and membership data.
Obtain pricing indications from reinsurers.

Design a holistic risk strategy with custom stop-loss and/or reinsurance protection.

Assist in reinsurer selection, bind stop-loss agreements and provide ongoing support.

CLAIMS AUDITING

PINNACLE SOLUTION Our team of risk managers analyzes your claims data to identify common payment errors that result in rising stop-loss premiums. In this example, we would combine claims of all HMO players along multiple dimensions and would typically find errors in upwards of 3% - 5% of claim payments, which would then be detailed in actionable reports for initiating recoveries.

Payment Error
Multiple HMO carriers delegate health care risk to a Primary Care Physician Group in return for capitated monthly payments. The HMO processes claims on behalf of the medical group with little incentive to oversee payment integrity. The medical group must manage the total cost of care within the capitated revenue model while having no reliable system to validate the HMOs' payment methodologies.

Pinnacle Solution
Our team of risk managers analyzes your claims data to identify common payment errors that result in rising stop-loss premiums. In this example, we would combine claims of all HMO players along multiple dimensions to find errors in upwards of 3% - 5% of claim payments. Then we'd provide actionable reports for initiating recoveries.

Duplicate Payments

Fee Schedule Misapplication

Fraud, Waste and Abuse

Incorrect DOFR Interpretation

Upcoding/Incorrect Procedure

Payment + Logic Errors

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