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Employer Stop Loss is coverage that reimburses Self Funded ERISA exempt employers for catastrophic claims incurred by their employees. Coverage is typically based on a billed charge. Reimbursement occurs after a specified deductible is satisfied and is typically subject to a co insurance percentage. Specific and Aggregate coverages are routinely purchased together to provide both an individual and total budget protection for the employer. Coverage is usually proposed in either a 12/15 or 15/12 month terms.

Employer Stop Loss is available to provide coverage on both a Specific and Aggregated basis. Coverage is bid to A 'Best' rated carriers on groups of 150+ lives, and is usually accompanied by Life and Disability insurance options. Pharmacy coverage is included where not separately bid under a fully insured Pharmacy Benefit Management program. Vision, Dental, Mental and Transplant carve out coverage is available where desired by the client to complete the benefits package. Discounted access to non exclusive national PPO networks manages the cost of both in-area and out-of-area care.

HMO reinsurance is coverage that reimburses the HMO for catastrophic claims incurred by their insured membership. Reimbursement occurs after a specified deductible is satisfied, and is subject to a co insurance percentage and an Average Daily Maximum Per diem limitation.

Specific coverage is provided along with Insolvency and/or Conversion coverage, as is required by state law, and is bid to A 'Best' rated carriers who compete for the business. Coverage is typically proposed on a 12/18 month term.

Aggregated coverage (see Capital Aggregate) is available to approved clients within a Capital Aggregate Reinsurance program. Pharmacy programs are managed on both a risk and non risk basis. Discounted access to non exclusive national PPO networks manages the cost of both in-area and out-of-area care.

Provider Stop Loss is coverage that reimburses medical providers for catastrophic claims incurred by their capitated HMO or Self Funded Employee membership. Reimbursement is calculated on provider costs, and is subject to a co insurance percentage and Average Daily Maximum per Diem limitation. Specific and Aggregate coverages may both be available. Aggregate coverage is usually unavailable. Coverage is typically proposed in a 12/18 term.

Coverage is bid by A 'Best' rated carriers. Pharmacy and transplant carve out agreements are widely available to transfer high dollar unpredictable risk. Discounted access to non exclusive national PPO networks manages the cost of both in-area and out-of-area care.

Coverage is provided for protection against an individual's catastrophic claim incurred by a self funded employer, self insured health plan, hospital, Physician Hospital Organization (PHO), Independent Practice Association (IPA), or Managed Care Organization (MCO) from an insured member during a calendar year. After satisfaction of the selected retention amount, reimbursement is usually subject to an agreed upon co-insurance percentage.

This policy affords coverage for medical charges and administrative costs in the event of practice insolvency while in a capitated agreement. Different from a Surety Bond or Capital Aggregate program, this program requires neither a Letter of Credit nor carrier indemnification. It is priced at 8% -12% of policy limit.

Pharmacy expense for many years now has increased faster than just about every other insured medical expense by category. Now, more than ever it is important to review account profiles and manage key components that DO respond to management, and avoid spikes in pharmacy expenses that blow the budget. Where reliable data is available, pharmacy risk contracts are available and offer effective risk transfer and benefit-management. Our process involves bidding to several well established venders at no additional charge, and assembling the most favorable terms with reliable pharmacy benefit managers able to stand behind their contract. This involves understanding your unique risk profile (experience), and ceding the stop loss/reinsurance to eliminate unpredictable risk. Contracts are available with and without risk to employers, or carriers offering a pharmacy benefit.

This type of financial guarantee bond is placed between the capitating HMO and the provider group as a safeguard against insolvency or bankruptcy. Different from the standard types of surety bonds which require 75% collateral, approved provider groups do not have to freeze their assets through an ILC. It is priced at 2% of face.

This contract transfers the risk of the pharmacy to our PBM ally. Clients are offered a full range of benefit designs and costs to tailor the program to the market segment. The program is reinsured with an A+ 'Best' rated reinsurer.

Provider Risk offers an instant network of 3,300 hospitals, 350,000 practioners, and 47,000 ancillary services providers. This is usually a non-exclusive contract offering clients maximum flexibility. Transplants are case-rated and include most follow-up office care.

All managed care entities must possess E&O to protect against unforeseen liability claims. Our brokerage allies provide the best coverage with 'A' rated carriers at the lowest cost. Today rates are varying 100% for identical coverage with A-rated carriers.

Coverage is provided to the director and officers of the corporation above what is provided in the E&O coverage. Our E&O expert specializes exclusively in managed care liability coverage, assuring member clients the richest coverage at the best program cost.

Coverage is designed specifically for self-insured hospitals to cover their employees' medical claims. This special program offers significantly lower premium cost as the reimbursement basis reflects actual provider costs.

Aggregate Programs

Coverage is provided against an entire population's budget overrun in a calendar year. Coverage typically reimburses the policy holder when claims exceed 110 percent to 125 percent of the average annual claim volume.
This is an aggregate reinsurance program which provides two major features:
  • Aggregate reinsurance attaching at 100% (not 125%, as is typical).
  • Capital placed on the client's Balance Sheet of $1-$2 million. The capital is priced at 5% of placement.
This product offers a very competitive alternative to the venture capital markets which typically requires equity, 15%-20%+ equity appreciation, pay out in less than three years, and 10% interest.
Securing true aggregate coverage is most challenging in the market today. However, Inner Aggregate or Aggregating Specific Deductible policies are widely available. In a Hospital Aggregating Specific policy, coverage is provided for hospital inpatient charges on a specific (per person per year) bases. This program (double deductible, single trigger pay out) reimburses the policy owner after the specific recoveries exceed a the Aggregating (summed) Specific deductibles stated in the policy. The first claims are internally funded, and paid immediately by the client to itself. Because no loads are placed on internal funds, premium costs are significantly discounted.
The Aggregate Capital program reimburses the client after the total capitation budget, risk corridor, and line of credit have been exceeded (single trigger pay out). This state of the art program combines capital access with aggregate reinsurance providing superior coverage at a reasonable cost.
The Provider Operating Deficit Protection program (double trigger pay out) consists of a piggy backed $100,000-$200,000 specific stop loss combined with an Aggregate coverage. The coverage pays the lessor of the Specific recovery, or brings the client back to their target Medical Loss Ratio. The policy pays out on a Specific basis, until the targeted Medical Loss Ratio is restored to the 85th-100th percentile. This policy offers about 60% savings over a stand alone Specific coverage.
The Capital Credit Aggregate program (double trigger pay out) consists of a piggy backed $100,000-$200,000 specific stop loss combined with an aggregate coverage. The coverage pays the lessor of the Specific recovery to bring the client back to their target Total Capitation Budget. The policy pays out on a Specific basis, until the Total Capitation Budget is restored to the 85th-100th percentile. This policy offers about 50% savings over a stand alone Specific coverage.

Insurance Consultation

Remember, nothing moves price and coverage like competition.

Today's ever increasing competitive climate is forcing self funded employers and managed care organizations to do more with less. Our network of strategic partners offers the busy executive turn-key access to save on competitive group liability insurance needs. Young managed care organizations regularly overlook these easy hits which save lots of money.

In the areas of: Self funded Plans, Self Insured Medical plans, Risk Management, Case Management, Transplant, Reinsurance, ACA Plan Offerings & Compliance, Provider Excess Loss, HMO Reinsurance, Employer Stop Loss, Group Insurance, TPA Administration, ASO Administration, Broker Standards, Professional Liability, Errors and Omission, Directors and Officers, Managed Care Liability, and Managed Pharmacy Risk Programs, our access is second to none.

Allow us the opportunity to introduce a resource specialist capable of rousing the market on your behalf.

Educational Programs In Managed Care & Reinsurance

Once we write your contract, we don't just go away.

We understand that Stop Loss Reinsurance can be confusing to everyone who has to deal with it - the administrative staff who actually file the claims and the health care executives who have to know how Reinsurance fits into the larger corporate picture.

For all of those needs, we can provide on-site training for Boards, self funded employers, self insured employers, fund managers, physicians and health care executives. And we can customize that training to your particular situation.

See our Articles for topics that are available now.

Claims Discount Service

Catastrophic case discounting provides substanial relief for member clients. Savings average 15-50 percent, but can be negotiated at higher levels. Discounting is available both pre and post incurral of services.

For selected clients, free audits of claims over $5,000 are available to identify overpayments and misguided care. Provider Risk assists attorneys, employers, agents, brokers, fund managers and consultants with overcharging issues and allegations. We are able to effectively audit all federal and commercial charged schedules.

Claims Champion Service

Provider Risk's exclusive Claims Champion Service offers the busy finance department stop loss administration. The service begins with our CPA coordinating claim data downloads directly from the contracted HMO. Monthly Premium Remittance & 50% of Retention Reporting, and actual claims submission are included. Our Vice President of Claims, Bridget Jones, RRA, is available to personally hand-deliver claims on site at the carrier's location.

International Medical Programs

Provider Risk represents direct access to Lloyds of London, and many other A+ rated reinsurers. Provider Risk also represents internationally available medical insurance, that includes US-eligible care.

Cooperative

The Cooperative program involves a dedicated organization of your risk into a Cooperative. As the details of this are confidential outside of the Cooperative program and membership, we encourage you to call for information on participation in the program. The essence is in grouping your risk into a purchasing Cooperative to increase savings and coverage while lowering agent fees on the block of business. Bargaining power is significantly increased as the Membership learns to work together, thereby improving the chance of carrier renewal in the most competitive light. Consulting fees are fixed, and discounted to maximize participation.

Medicare+C - Medicare Plus Choice

Medicare+C is a specific program of stop loss that reimburses the hospital and/or physician group for Medicare Part C capitated members. Reimbursement occurs after a specified deductible is satisfied, and is subject to a co insurance percentage and an Average Daily Maximum Per diem limitation.
Specific coverage is provided along with Insolvency and/or Conversion coverage, as is required by state law, and is bid to A 'Best' rated carriers who compete for the business. Coverage is typically proposed on a 12/18 month term.

Disease Management Reinsurance

Disease Management Reinsurance is insurance that reimburses the disease management company for unexpected medical claims in excess of a fixed contracted case rate. Aggregate coverage is typically placed, and is subject to a deductible and coinsurance percentage.

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