Provider Excess Loss Insurance Capitation Stop-Loss

Managed Care Stop-Loss

  • Health Plan Reinsurance.
  • Provider Excess Insurance.
  • ACO Stop-Loss.
  • Financial Analysis.
  • Claims Service Center.

What is provider excess loss insurance?

Provider Stop-Loss/Provider Excess Loss coverage is coverage for catastrophic claims incurred based on a capitation agreement between the health plan and a provider.

Provider Excess Loss insurance is designed to protect providers from the effect of catastrophic medical claims.  Stop loss “kicks in” and picks up the tab when a claim exceeds a pre-determined amount (deductible/retention). A certain percent of health claims could be catastrophic, meaning a claim that requires extensive medical treatment at a very high cost. For example, burn victims, neonatal, trauma, cancer treatment, etc.

By insuring against catastrophic health claims with a stop-loss policy, you are passing excess risk to an insurer and protecting your company from financial hardship in the event of a catastrophic claim. Stop-loss insurance helps you reduce unpredictable risk.

Who needs it?

Any hospital, PHO, IPA, ACO, health system, hospital system or medical group that provides care for health plan members on a capitation basis.

Things to watch out for:

  • Stop loss policies sometimes contain exclusions and escape clauses that could leave you vulnerable.
  • Incorrect risk and utilization assessment
  • Not shopping the policy application to all available carriers
  • Per Diem maximums of fee schedules that do not cover your risk.
  • Deductibles set at the wrong levels that create higher premium payments.

Broker vs Insurer?

In most cases, it’s better to negotiate a stop loss policy through a broker, rather than working directly with an insurance company.

Why?  Insurance is a business.  The less claims paid = the more profitable the insurance company.  A broker is working for you.

McPhee Process

  • Thorough risk and utilization assessment.
    We accurately assess the various risk and utilization factors.  We produce a tailor-made policy that fits your requirements.
  • We “shop” the policy to a variety of carriers.
    Most brokers are affiliated with only a handful of carriers, this limits options.
    McPhee & Associates is affiliated with a large selection of carriers giving us much better options.
  • The language must be checked.
    The selected carrier that gave the best options, now takes the policy outline and “translates” it into a final policy contract. Our representatives make sure that this language no ambiguous.  We scour each contract to locate clarify/eliminate all phrases and clauses that would be unfavorable to you.
    We include every available benefit, options and discount available to you.
  • Policy Implementation.
    Most brokers leave you on your own at this point.  Our full-service support department rolls up its sleeves and helps implement your policy.
    Implementing a policy–especially a major one–can be a nightmare.  Our goal is to make it as smooth as possible.  We send out one of our seasoned consultants to train your personnel on all aspects of the policy, maintaining compliance, what reports are necessary, how to identify potential claims, what information is needed to present a claim. This service is complimentary to all of our clients.
  • On going support.
    Our support goes way beyond just answering questions.
    Just one late–or omitted–report can determine whether you get reimbursed on a claim.  We take a proactive approach.  We monitor required reporting to assist you in getting the necessary reports in on time.  We spot-check the paperwork to see that everything is in order.  We monitor the run-out period of your policy to help you make sure that compliance is maintained and any outstanding claims are paid.
  • Claims reimbursement.
    We work aggressively to get your claims reimbursed in a timely fashion (usually 30 days or less).
    How?  We have already been helping you maintain your reporting and paperwork requirements.
    In fact, our clients have the lowest claim-rejection-rate in the business.
    If there is a problem, we are there for you, pushing the claim through.

Why McPhee?

It’s safe to say that we are the most experienced provider excess loss brokers in the country.  We were the first and only broker to blueprint and develop a line of stop loss insurance for capitated providers in 1983.  We developed the original format for stop loss contracts and it is still in use today.

We often get asked why do we go to such extremes to provide service–and how can we afford to do it.

The answer is simple.  Other brokers use the percent of their premiums to maintain large sales forces and expensive advertisements.

At McPhee & Associates, we determined that the best way to get clients is to keep them.  We invest our percent of your premium into providing you with expert advice and the best support available anywhere.

What states do we service?

California, Colorado, Connecticut, Delaware, Florida, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York, Nevada, North Carolina, Ohio, Oklahoma, Oregon, Texas, Tennessee, Utah, Washington and Wisconsin.

To learn more about managed care brokerage and consultant services at McPhee & Associates—contact us or call (818) 541-7900.