Protects Medicare Advantage, Managed Medicaid and Commercial HMO health plans against
Protects medical groups, IPAs, PACE providers, and 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.
Targets excess costs for specific episodes of care under CMS or commercial payor bundled
Helps ACOs to satisfy CMS’s
capital requirements and
Pinnacle Brokers Insurance Solutions, LLC provides reinsurance products and services for organizations that accept capitation and risk-sharing under Medicare Advantage, Managed Medicaid, Commercial, and Value-Based Care payment models.
WHO WE SERVE
HMO Health Plans | Medical Groups | Independent Physician Associations |
Accountable Care Organizations | Management Services Organizations | PACE Programs | Integrated Delivery Systems
MANAGED CARE SUPPORT
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 exposure,
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.
Our team of risk managers analyzes your claims data to identify common payment errors that result in rising stop-loss premiums. We combine claims of all HMO players along multiple dimensions and typically find errors in upwards of 3% - 5% of claim payments, which are detailed in actionable reports for initiating recoveries.
Fee Schedule Misapplication
Fraud, Waste and Abuse
Incorrect DOFR Interpretation
Payment + Logic Errors