McPhee & Associates Services Overview

A Brief Overview of McPhee’s Organization and Managed Care Experience

McPhee & Associates, Inc. was founded in 1983 specifically to work with the Managed Care Industry to provide new markets for stop loss reinsurance. While working as a Lloyd’s of London broker, the founder A. Lloyd McPhee, created a new market for HMO stop loss reinsurance. This provided much needed competition to overcome the exorbitant rates charged by the two insurers offering stop loss reinsurance coverage at that time.

Located in Southern California, McPhee & Associates services many local hospitals, medical groups, health plans and health systems with reinsurance and provider stop-loss insurance. References can be supplied upon request.

We have long standing relationships with the specialized carriers in the stop-loss market. McPhee & Associates has access to more markets than any other single broker.

McPhee’s Staffing & Services for your Account

An account executive specifically assigned to you as a facilitator to ensure that the following responsibilities are met:

  • A thorough assessment of risks or financial
  • Development of insurance contract language that follows your contract
  • Marketing the benefit package to
  • Ensures that the insurer issues the coverage according to the agreements reached during the proposal and negotiation
  • Arranges an installation meeting with you and your appropriate staff at the initiation of

the contract period to go over the terms and conditions of the coverage binder to thoroughly clarify your contractual obligations for reporting and claims submission.

  • Ensures that the reporting and claims processes are handled

A Claims manager whose responsibilities include working directly with the client’s personnel to make certain stop-loss contract obligations are met throughout the year. These include:

  • Ensuring that monthly reports are developed and submitted within the policy provisions.
  • Reviewing all insurance claim submissions for accuracy and
  • Transmission of claims to the
  • Follow-up for claims reimbursement within 31 business
  • Review of claims reimbursement to ensure proper
  • Handles insurer’s inquiries on your
  • Provide you with a claim summary reflecting claims submitted, reimbursed and pended.
  • Provide you with a history of claims submission and reimbursement for each and every year you are our client.

An account assistant whose responsibilities include:

  • Review of insurance policy
  • Follow-ups for endorsement and changes as
  • Maintaining the accounts files for easy reference and
  • Answer client’s questions as to coverage, benefits and policy

Initial Implementation Meeting

  • Have an initial meeting with you to gather the information required to do a full comprehensive proposal and a claims/benefits cost
  • Do a complete analysis of the information and determine the burning claims costs for the current and past two
  • Discuss with you the results of our analysis and discuss benefit plan design and alternatives.
  • Review all proposals and complete an analysis of benefits and
  • Discuss with you the preliminary results of the initial
  • Renegotiate with the underwriters of the 3 or 4 most responsive insurance carriers, which have most closely met our RFP benefit structure and policy terms and conditions, to obtain their best
  • Meet with you to present a full report of the results of our marketing effort which will include our recommendations and why, and assist in the selection of the stop-loss carrier based on their product design, service responsiveness and

We work on your behalf and directly with you not only at the time of policy negotiations, but also throughout the year to help your personnel handle all of the requirements of the stop-loss policy, including monthly reporting and claim submissions. We feel that it is a team effort between both parties. We make sure that anyone involved in any way with the stop-loss coverage has a complete and thorough understanding of this coverage.

This may include your claims personnel, contracts department, UR nurses, Medical Director, finance department and whoever else may be involved with this process.

In addition to the initial plan implementation meeting we provide training as needed to personnel who are or become involved with the administration of the coverage.

Claims Strategy and Recovery Monitoring

McPhee & Associates has always felt that stop-loss is all about claims recovery. It doesn’t matter that you received a great rate if your claims aren’t paid. There are two cost areas in your stop-loss plan. One is the rate that you pay, and the other is the loss of revenue through poor claims recovery. Poor claims recovery can be due to:

  • Poor stop-loss plan design
  • Unusually restrictive claims practices of the insurer
  • Lack of knowledge of the insured in submitting claims
  • Lack of knowledge or experience by the claims examiners at the insurance carrier in handling managed care claims
  • Poor response time from the carrier for various reasons
  • No one representing your interests to ensure a smooth claims process

Claims and service personnel at McPhee & Associates work directly with your personnel to overcome all of these situations to ensure the maximum recovery of your claims.

We help generate all reports and claim submissions, verify them for accuracy and completeness, and then transmit them to the insurer.

Following is a detailed description of how this process works.

  • Monthly reports and descriptions of potential claims are a requirement of every insurer. We help you monthly to generate these reports. We review them for accuracy and completeness and verify any unclear data, then transmit them to the
  • Receive all insurance claims data for initial review to ensure that all documentation is present. If any part of it is unclear, such as codes and amounts for certain procedures,

we first clarify it with you and make certain we transmit an easily payable claim to the insurer. The electronic claims submission process falls apart if these actions are not done properly. We keep a record of all claims and log them into our system for easy reference and tracking of payments.

  • Follow-up with the insurer to verify the receipt of claims and to handle Insurer’s questions, and to assure quick turnaround time for
  • Receive all insurer’s claims queries, many of which can be answered or handled without having to refer to you. Sometimes we simply tell them that what they are asking is unnecessary and arbitrary. Other times we resolve issues with them without the necessity of involving

Since we work with them on a routine basis and have their respect, we can accomplish a lot for you that otherwise might have become a difficult problem.

  • Review all claims calculations and reimbursements for accuracy. Discrepancies are identified and

Fee schedules are confirmed to ensure that proper geographic area and conversion factors are applied.

Responsibility matrices are checked to ensure that charges are applied to the appropriate hospital, professional or health plan’s responsibilities. We question incorrect allocations so that you receive proper reimbursement for your areas of risk.

  • Use our extensive claims experience and our knowledge of codes (and our relationship with the insurer) to negotiate for payment of any unclear charges (such as medications for treatment of uncommon diseases, or for home therapy in lieu of hospitalization).
  • Provide a specific claim summary showing eligible charges for each submitted procedure and payments, as well as clarification or explanation of any disallowed amounts.
  • Provide reports of all claims activity to date including summaries of all submitted charges, paid reimbursements and pending claims. A record of these is kept year to year.

All of these steps guarantee maximum claims reimbursement, timely reimbursement payments and a reduced rate of claims refusal.

Binder and Issuance of Insurance Agreement (policy)

Once the insurer is selected, we see that the coverage is issued according to the agreements reached during the proposal and negotiating process.

  • We issue a detailed coverage binder to you and to the insurer that spells out rates and benefits and each and every change, addition or deletion that was agreed upon. This leaves no room for argument when the policy is issued or claims
  • We thoroughly review the issued Insurance Agreement (the policy) to make certain it is in keeping with all negotiated terms and conditions, or get it changed so that it

Therefore, you are secure in knowing that you are getting the coverage you expected.

Installation Meeting

We arrange an installation meeting with you at the initiation of the contract period to deliver the Insurance Agreement, go over all its terms and conditions and to thoroughly clarify your contractual obligations for reporting and claims submissions. We invite you to bring in to this meeting your key staff who have a bearing on the operation of the Insurance Contract. Usually present is the CFO, claims personnel, contracts manager and UR or case management nurses.

We bring in our key personnel who have been involved with the negotiating process and who will be involved with claims and service. We also invite claims personnel from the insurer to get them directly involved and interested in providing optimum service to you and your staff.

Following is the format we follow in this meeting:

  • Review the Insurance Agreement and how it works. Discuss definitions of specific terms and their effect on claims, such as “contracted” versus “non-contracted”. Review fee schedules, per diems etc. so that all present understand how the stop-loss coverage is
  • Go over the relationship between the HMO, the provider, McPhee & Associates and the Insurer, and thoroughly review the risks that have been transferred to the
  • Discuss how your key personnel can interact with each other and with our staff to efficiently provide claim information for maximum and timely
  • Establish administrative procedures, reporting requirements, adding new capitation agreements, or changes in them, during the contract year. We provide an instruction manual and the appropriate forms for this purpose.
  • Review claims reporting and submission procedures, monthly reporting of members and potential claims, and submission of claims for reimbursement. We persuade the insurer to accept your current method and format for reporting and submitting of claims if all the required information is included in your format, including electronic data

This meeting results in a full orientation to the Insurance Contract and its requirements, and in establishing a working relationship between all parties to the end that the benefits of the stop-loss coverage are fully maximized.

Insurer’s Value Added Benefits

Many insurers offer “value added benefits” which may be useful to you. We make certain that they are made known and explained to you. Such benefits include:

  • Organ transplant facilities at deeply discounted charges which include some preliminary work-up, donor charges, and pharmaceuticals for 30 days and 12 months follow-up.
  • National Provider Network for referrals or emergency care at discounted charges and in which you have an element of control over your members’
  • Case management activities such as assistance in identifying high-risk pregnancies and patient education to encourage the patient to have an active involvement in their

We have the insurer’s representative present these to you so that you can make an informed decision as to their appropriateness for your organization.

Summary

As you see, we play a very direct role in the entire insurance process. We recognize that the objective of the Insurance program is not only to get for you the best value in coverage and price from a reputable insurer, but also to see to it that your stop-loss program operates smoothly and effectively, and that claims are reimbursed accurately and in a timely manner.

We built McPhee & Associates as a service organization first and foremost. Many brokers have larger sales forces than we do. None have a service organization that comes close to ours or that compares in knowledge and experience.