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.
Protects Medicare Advantage, Managed Medicaid and Commercial HMO health plans against excessive claims by limiting catastrophic claims.
Targets excess costs for specific procedures and episodes of care under CMS or commercial payor bundled payment models.
Helps ACOs to satisfy CMS’s
capital requirements and
Pinnacle Brokers Insurance Solutions, LLC is a leading insurance brokerage that provides reinsurance and risk management solutions to Manged Care Organizations.
MANAGED CARE SUPPORT
and membership cohorts.
Evaluate enterprise-level financial profile and risk mitigation program.
Collect claims and membership data.
Obtain pricing indications from reinsurers.
Assist in reinsurer selection, bind stop-loss agreements and provide ongoing support.
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.
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.
Fee Schedule Misapplication
Fraud, Waste and Abuse
Incorrect DOFR Interpretation
Payment + Logic Errors