FALL 2004
IN THIS ISSUE
    A MATTER OF WHEN, NOT IF
    UP CLOSE
    RX TREND
    RISK MANGEMENT
 
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SHORT STAY/HIGH DOLLAR CLAIMS:
VOLATILE RISK NOT COVERED BY TRADITIONAL REINSURANCE

In July 2004 a health plan had a member admitted for a trauma to an out of area medical center. The plan negotiated a discount for a six-day stay and the final bill was $575,000. Under the plan’s reinsurance coverage, the average daily maximum (ADM) for out of area claims was $6,000, which for the six-day stay equated to $36,000 toward satisfaction of their $150,000 deductible. The plan received zero reimbursement for a $575,000 claim.

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A Matter of When, Not If  


If you're like many executives at health plans across the country, you may have a nagging feeling a claim in excess of a million dollars could be coming your way at any moment. That feeling may indeed be a warning signal of things to come.

According to a recent report on the frequency of catastrophic claims, the incidence of claims in excess of one million dollars has tripled over the last three years. Many of these claims are in the areas of transplants, multiple and premature births, burns and trauma. They also happen as a result of complications following what is often routine treatment and in complications with chronic conditions requiring costly, long-term treatment. Increasingly, these claims are also occurring over short periods of treatment, often in non-traditional settings, and as a result are not adequately covered by traditional approaches to reinsurance.

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