Health & Welfare Consulting

We work with you on a proactive and forward-thinking basis. We begin our engagement with a meeting to establish and document overall and specific goals, objectives, and needs for the forthcoming 12 to 18 months. Our goal is to create knowable outcomes around administrative, compliance, financial and strategic results. We hold regular meetings to provide status updates as well as continuously recalibrate and document baselines, benchmarks, and means and methods of measurement. Specific services include but are not limited to:

• Creating benefits strategies which reinforce goals around human capital such as recruitment, retention, and productivity
• Technical expertise and strategic support so that the client can continue to develop, implement, and administer forward-thinking program changes
• Guidance on emerging financial, administrative, regulatory, and industry considerations
• Develop, implement, and help manage needed timelines for decisions around program changes, open enrollment, financial quotations, renewals, and other significant events
• Advise the client and act as a liaison in contract negotiations and renewals with vendors including coordination of reporting and overall vendor management issues
• Educate and communicate initiatives directed to the senior management team and/or benefit plan participants.
• Discuss and coordinate information with other consultants employed with the client
• Assist and advise in preparation of “requests for proposal” for vendors and/or services necessary to implement benefit plans
• Aid the client in establishing the foundation and working environment for long-term partnerships with vendors
• Develop, document, and implement performance standards for vendors. Areas for consideration include financial cost and accuracy, administrative quality, and accuracy, as well as overall customer satisfaction
• Negotiate vendor agreements that appropriately assign, limit, and transfer legal, financial, and administrative liabilities

Audit and Compliance: two words that very few people love. Luckily, our team is cut from a different cloth. We pride ourselves on our use of unique data hierarchies and critical thinking in the areas of audit and compliance. We work diligently with our clients to explain administrative, financial, and strategic implications of the law and emerging regulations. We proactively offer analysis and interpretation on both the intended and unintended consequences for plan sponsors. We provide tactical and strategic thought as well as advice for each client based on specific circumstances. Our audit and compliance services include but are not limited to the following:

• Authoring and release of legislative and regulatory updates
• Provide assistance and advice with review of benefit programs on a continuing basis to ensure compliance with federal requirements and adequacy of benefits with respect to other plans
• Provide information on pending or new legislation and changes in tax law, as well as benefit and funding trends that may affect the benefits program, applying assumptions to various scenarios
• Audit, develop, and document appropriate client policies and workflow for regulatory compliance
• Conduct administrative, operational, and clinical vendor audit, which also includes review of data security as well as internal audit and controls.
• Perform discrimination testing for insured and non-insured arrangements
• Advise and assist the client with writing plan modifications and new plans, submitting written reports and other documents as required by the Federal Government
• Assist with required filings such as Form 5500s, ERRP and minimum credible coverage
• Review all plan documents, contracts, insurance policies, and employee communication for accuracy, applicability, and consistency

Our Quality Efficacy & Cost Analytics (QEC) merges the talents of our diverse group of experts with a proprietary audit tool. QEC identifies aberrant clinician utilization, referral, and billing practices, indexes claims by service type and modality, and correlates those claims to reimbursement mode by provider while adjusting to local practice patterns. QEC identifies and quantifies the causes and costs of "claim leakage" and the effects of provider revenue cycle enhancement. It examines clinical practices, costs, and outcomes by provider.

QEC capabilities make it an invaluable audit tool which brings transparency to provider behavior and carrier management skills. It enables recoupment of previously made inappropriate payments. Additionally, it identifies efficient, high quality providers for use by plan sponsors, participants, and network entities. Its value to clients will continue to grow as Health Care Reform results in provider network reconfiguration and CDHP requires increased information to be placed in the hands of the participant.

QEC OBJECTIVE: Identify opportunities for the Company to recover unnecessary claim dollars driven by the above factors. Measure potential savings and develop a recovery approach to maximize savings.

• QEC has been used to provide analytics to Fortune 200 companies as well as various Federal and State agencies. Typical results identify opportunities and recoveries around approximately 15% of providers and 5% of plan costs.
• QEC is a proprietary data analytics tool which identifies aberrant provider utilization, , referral, and billing practices. Analysis is indexed by service type or modality of the provider, at the claim and claimant level, and adjusted to local practice patterns.
• Identifies and quantifies the causes and costs of “claim leakage” resulting from provider revenue cycle enhancement practices and the carrier’s corresponding inability to manage or deter these practices.
• A team of physicians, pharmacists, actuaries, and public health experts examine clinical practices, costs, and outcomes. Areas of focus include but are not limited to:
  • Inpatient readmissions, ER utilization and/or the use of antibiotics following a previous inpatient or outpatient procedure.
  • Percentage and instances of previously denied claims being reimbursed when resubmitted utilizing different coding practices by the provider.
  • Linkage between bed days and reimbursement mode, practice patterns based on ownership of the provider as well as transfers based on reimbursement, benefit maximums or economic ties.
  • The commercial benefit equivalents of “never events” as defined by Medicare which are subject to non-payment.
  • Claims for injectable drugs administered in the physician’s office which include “J” codes.
  • Frequency of office visits with diagnosis of “Signs and Symptoms”.
  • Mismatch of professional and technical services where professional services are provided in a hospital outpatient setting leading to up-coding or medically unnecessary services.

RESULT: In the short and mid-term, the Company recovers significant costs associated with these unnecessary claim dollars (estimate 5%). In the longer-term, the Company utilizes these tools to minimize such future claim costs to mitigate future healthcare costs.

Our technical services team consists of actuaries, clinicians, economists, doctorates in public health, revenue cycle enhancement specialists, and other benefit experts. Our team utilizes proprietary data management tools to perform multi-disciplinary and integrated population-based analysis.

We approach our large, complex clients as if they are, in fact, the insurer of their covered population. We assist by asking and answering detailed and non-standard questions designed to assess, abate, and manage risk. Our team takes great effort to identify the underlying causalities of risk, costs, and liabilities with particular focus on the "at risk" and "of need" segments of the client’s covered population who drive a disproportionate percentage of costs. Consideration is given to both chronic care underlying conditions, which act as "complicators," and the identification of emerging large claims, as well as the management of existing large claimants.

We assess, quantify, and create integrated solutions regarding risks and costs that apply across multiple plan types. An example of this work is recognizing the cost and issues surrounding high-cost medical claimants who are also subject to EAP, FMLA, and disability benefits. Our technical services include but are not limited to:

• Data collection and analysis of risks, costs, and liabilities utilizing a unique hierarchy of varying data sets
• Conduct internal actuarial and clinical analysis of claims experience, premiums paid, claims reserve, and fund requirements as requested
• Establish appropriate accrual rates and reserves for all self-insured plans, as well as determine the appropriateness of rates and reserves put forward by carriers for insured arrangements
• Maintain records of financial and claims experience, condition, and progress of the client’s plans. Provide the client with quarterly reports
• Development of customized reporting packages specific to individual client needs
• Analyze and integrate all available clinical data from the sponsored programs to establish proper risk and cost baselines and then project the possible effects of various health risk management tools
• Assess the client’s tolerance for risk and then develop corresponding risk management strategies in order to lower plan costs and improve predictability. Appropriate risk management tools may include provider network and clinical management, plan design change, alternate contribution structure, multiple rate tiers and benefit classes, knowledge of carrier underwriting practices and state underwriting requirements, product composition, and selected funding arrangement
• Analyze the value of various network and clinical management alternatives around cost, value, appropriateness, and results. Create needed ROI models which quantify and qualify the value of such factors as satisfaction, absenteeism, turnover, and morbidity
• Provide needed Medicare Part D attestation and accompanying subsidy calculations
• Perform needed Discrimination Testing for IRC Sections 105, 125 and 129
• Calculate and provide FAS 106 and 112 liability studies
• Prepare alternate funding analysis including the possible use and implementation of a Captive entity, PDPs, and other available solutions