For large companies, self funding your employee benefits is the ultimate way to control costs and manage risk. By reimbursing the claims themselves instead of paying high cost premiums the savings can be boundless. Why pay the same high premium for an employee that barely uses their health insurance as an employee that has high costs medications and medical services? That’s where self-insurance comes in; and GMR as your third party administrator will help save you even more money!
Here’s how we control high costs:
Stop Loss Insurance
Medical stop loss coverage is put in affect to limit an employer’s liability on catastrophic or high-cost claims. The general assets set aside for the self-funded health plan are insured against unforeseen risks. Medical stop loss insurance provides “Stop Loss” for individuals’ claims that are higher-than-expected (Specific Stop Loss) as well as a cap on overall medical expenses across the entire employee base (Aggregate Stop Loss).
Specific Stop Loss
The employer is responsible to funds claims for an individual only up to the specific stop loss amount. In the event that an individual’s claims exceed the predetermined amount the reinsurance carrier would pay all claims above that threshold.
Aggregate Stop Loss
This is a pre-determined total amount for the entire group, setting a max out of pocket for the employer. This calculates the total dollar amount paid by the employer and caps the potential risk.
Types of contracts:
The most common types of contracts are 12/12 , 12/15 or a 15/12. A 12/12 contract covers the employer on a 12 month billed and incurred basis. The 12/15 contract allows for a lag on the claims billed after the 12 month covered period for an additional 3 months. The 15/12 contract allows the employer to roll in the lagging bills from the previous plan year. This is generally utilized when the previous plan year opted in for a 12/12 contact and is experiencing high utilization at year end.
Worksite Wellness
Worksite wellness is more than just adding benefits to your employees’ package; it is a process of creating a workplace environment where employee health becomes an investment. A carefully coordinated wellness program broadens the vision and creates a purposeful objective of improving a company’s overall health and productivity.
According to Harvard researchers, comprehensive wellness programs have shown over a 3:1 ratio in medical savings and a 2:1 ratio in productivity savings for every dollar invested. Proper wellness program are built into the workplace culture to enlighten and educate the employees about their health and make them aware of the tools at hand to keep all your employees actively aware of their health.
Utilizing the proper wellness program is the key to happy and health staff and work environment.
Find out more [Link- email ] about how we can help you incorporate the right wellness program for you and your staff.
Reviewing Claims
Utilization Review- Before high cost services are rendered providers need to obtain a pre-authorization. This allows for surgeries, high cost imaging, long term therapies and hospitalizations to be reviewed by a medical professional on our team.
When someone is admitted to a facility on an emergency basis we have the admission retroactively reviewed and the stay reviewed concurrently while keeping in touch with the hospital to ensure all measures are being taken to get the member feeling better and ready for discharge.
Other services for cost management that we offer are:
Case Management- When someone is ill it is almost impossible to think clearly, that’s when a nurse case manager reaches out to the member and coordinates with their doctors and family while guiding the member to go to in network providers and second opinions. This essentially helps reduce the cost that may have been incurred.
Review for Abuse & Fraud
Unfortunately, Health Care Fraud is currently rampant. It comes in many different forms, providers billing duplicate charges, Facilities billing excessive amounts, Copays, Coinsurance and Deductibles being looked away from in order to attract patients to out of network providers, misleading diagnosis codes, the list goes on. In addition to the fraud there are numerous ways to misuse health insurance, members going to the Emergency Room for services easily received at a doctor’s office, losing and misplacing medications, “sharing” insurance cards and so on. GMR stays ahead of all this. By scrupulously reviewing claims we see the providers that perform the exact same test on every patient every time they come to be seen. We see the patient going to the ER for an ear ache. All claims are first passed through our system and then analyzed based on the system’s suggestions.
Disease Management- There are nine prevalent conditions that guidelines are established for to improve the individual’s health:
- Asthma
- Chronic kidney disease (CKD)
- Chronic pain (osteoarthritis, rheumatoid arthritis or low back pain)
- Coronary artery disease (CAD)
- Congestive heart failure (CHF)
- Chronic obstructive pulmonary disease (COPD)
- Diabetes
- Hyperlipidemia
- Hypertension
Members with chronic conditions work one on one with registered nurses who are trained in assisting the members take care of themselves and set goals for their health.
Other ways of managing risk
Biometric Testing
A biometric test is a health screening that measures the physical characteristics of employees in order to assess the overall health of the employee population. By testing such things as the employees’ height, weight, BMI, blood pressure, blood cholesterol, blood glucose, and fitness you can start to design a health and wellness strategy that will ultimately sav you money.
Maternity Management
Maternity Management programs provide education and support to pregnant woman to reduce instances of complications that result in high-dollar claims. Premature births affect nearly 450,000 babies yearly in the United States, costing the health care system more than $25 billion a year or about $50,000 per case. Maternity Management helps alleviate this cost by:
- Educating moms-to-be on ways to reduce risk factors for themselves and their unborn children
- Providing early intervention, detection of high-dollar claims and referrals to Maternity Case Management
- Providing value-added materials and educational literature
- Providing education, support and guidance to mothers before and after delivery
Teladoc
In today’s world everyone turns to the internet for answers and research. This is also true for health questions when doctors are not accessible and symptoms present. Teladoc is a way for health professionals to be available for a consultation before a member panics and runs to the nearest Emergency Room. What is even more beneficial to the employee is that with Teladoc there are no copays, coinsurances or deductibles so there is no reason to hesitate.
