MANAGED CARE

STOP-LOSS SPECIALIST

HMO Reinsurance


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

Specific Stop-Loss


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.

Bundled Payment


Targets excess costs for specific 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 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


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 exposure,
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. 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.


Duplicate Payments

Fee Schedule Misapplication

Fraud, Waste and Abuse

Incorrect DOFR Interpretation

Upcoding/Incorrect Procedure

Payment + Logic Errors