Capitation Provider/PACE Stop Loss Insurance

Capitation Provider/Managed Care Stop-Loss

  • Provider Excess Insurance.
  • ACO Stop-Loss.

What is provider stop loss insurance?

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

Stop loss “kicks in” and picks up the tab when a claim exceeds a specific amount (deductible/retention). A certain percent of health claims will be catastrophic, meaning a claim that requires extensive medical treatment at a 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. 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.

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 and needs.
  • 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 better options.
  • Policy language checked.
    Our representatives make sure that this language is not ambiguous. We scour each contract to locate clarify/eliminate all phrases and clauses that would be unfavorable to you.
  • Policy Implementation.
    Most brokers leave you on your own at this point. 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.
  • Ongoing support.
    Our support goes far beyond answering questions. Just one late or omitted report can affect claim reimbursement. McPhee & Associates takes a proactive approach to prevent this. We monitor required reporting to assist you in getting the necessary reports in on time. We spot-check the paperwork to ensure 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 Business days or less) with a full explanation of how the claim was adjudicated. If there is a problem, we are there for you, pushing the claim through.

Why McPhee?

It is 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 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.

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

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