Solutions for:
Health Plans & Insurers

Managed Care Providers
Self-Funded Employers
Taft Hartley/Union Funds
Business Coalitions & Associations

Hospitals and Hospital Systems





 

 



Evergreen Re helped us to recognize the value of transplant insurance and how it would help us get quality outcomes and provide our members with the best coverage. We have been very impressed with the coverage and service and just recently renewed a three-year contract.


~ Mike Bennington
Senior Director
National Rural Electric Cooperative Association

 

 

Evergreen Re Solutions

As a national healthcare consulting firm, Evergreen Re provides a wide range of reinsurance brokerage services and other risk reduction products and services that improve predictability and financial performance for health plans, provider organizations, self-funded employers, unions, business coalitions and associations.

~ HMO Reinsurance

~ Predictability Tools

~ Employer Stop Loss

~ Managed Care Provider Excess

~ Managed Care Professional Liability

~ Managed Transplant Insurance

~ Neonatal Management Services

~ NeonatalConsult.com

~ Evergreen Rx Pharmacy Consulting

~ High Cost Biological and Pharmaceuticals

~ Disease Management

~ Disputed Claim Management

~ Hospital Demand Forecasting

~ Advocacy -- We Work For You

~ Other Solutions

 

 

Reinsurance

As the largest managed care reinsurance brokerage firm in the country, Evergreen Re helps health plans and other managed care organizations throughout the country protect their capital and cash flow from catastrophic claims.

Working closely with Reden & Anders, an actuarial and consulting firm with the largest proprietary managed care database in the country, we have developed a series of tools to help you find the precise balance. Using some of the most comprehensive and sophisticated data analysis models in the industry, we can help you determine the right mix of reinsurance and capital to make those important decisions. We then place custom-designed coverage that helps you keep risks – and costs – under control

We also offer Shared Stop Loss, Treaty and Quota Share programs as well as Captives and other Risk Retention Programs for managed care organizations and providers.

For a free analysis of your current reinsurance contract, please email rtaylor@evergreenre.com

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Predictability Tools

Optimal Reinsurance Program™
This is one of our primary value propositions we use to help us select the reinsurer or product that offers the best value to the customer. The Optimal Reinsurance Program™ was developed in conjunction with a leading, national managed care actuarial firm. The components of this program include:

  • Theoretical Reinsurance Analysis™. With a thorough understanding of the evolving nature of risk faced by health plans, the purpose of this analysis is to enable health plans to optimize the combination of capital and reinsurance (covered services and retention) to achieve 95% confidence of maintaining their current surplus level at the lowest total cost of protection.

  • Coverage Structure and Marketing. We don't simply provide information to reinsurers; we package data in a proven format to maximize insurer response and competitiveness. We then utilize our broad access and significant leverage to help ensure our customers get the most efficient coverage available.

  • Net Cost Analysis. Recognizing that gross premium expense is not nearly as important as plan predictability and net cost of catastrophic transfer, Evergreen Re developed this analysis to determine the relative value of competing insurer (coverage) proposals.

  • Optimal Reinsurance Analysis. This analysis marries the results of the Theoretical Reinsurance Analysis with the Net Cost Analysis to point to the most efficient level of reinsurance. It enables final decision-making around the health plan's "appetite" for risk and surplus protection, including risk based capital goals.

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Employer Stop Loss

We help self-funded employers, coalitions, insurers and funds determine the most appropriate program to protect themselves against catastrophic claims and unpredictable losses. Specific Stop Loss insurance reimburses an employer for catastrophic claims incurred by a plan participant above a specific deductible, while Aggregate Stop Loss reimburses an employer for higher than anticipated health care expenses incurred by all plan participants. We also offer Shared Stop Loss, Treaty and Quota Share programs as well as Captives and other Risk Retention Programs.

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Managed Care Provider Excess

Evergreen Re can help your organization determine if you have the right type and the appropriate level of provider excess loss coverage at the lowest total net cost. As risk-bearing organizations take on many of the responsibilities and risk from health plans, our client services staff can help make sure you eliminate slow payment of claims that threaten solvency and destroy cash flow.

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Managed Care Professional Liability

In an increasingly hard insurance market, with unrelenting exposure to litigation, Evergreen Re can help you identify alternative solutions available, including best managed care errors and omissions insurance as well as liability insurance for the directors and officers of healthcare and managed care organizations.

Managed Care Liability Coverage needs to be solid and without exclusions if it is truly going to protect healthcare organizations, as well as their directors and management, from experiencing serious financial loss. While multi-district litigation and class action exposure have driven a hard insurance market, managed care organizations can protect themselves from the onslaught of lawsuits and evolving exposures by implementing sound risk management programs, identifying potential gaps in existing insurance coverage and understanding their potential. Working with a specialized team of managed care liability experts, Evergreen Re is now poised to offer managed care organizations the broadest reach to insurance markets in liability exposure, including Directors and Officers liability (D&O), and Errors & Omissions.

Directors & Officers Protection
The business practices and decisions of health care boards of directors are constantly under intense scrutiny from regulators and the public and they can easily become the target for litigations from employees, providers, customers, vendors, creditors, competitors as well as government agencies. While a managed care organization is at financial risk when a D&O claim is made, the personal assets of the organization’s management team are also at risk. D&O insurance can protect managers against personal liability. Key D&O exposure includes anticompetitive acts, shareholder liability and mismanagement.

Errors & Omissions Liability (E&O)
Traditional D&O protection does not address the most important managed care exposure area – claims arising from the day-to-day management of the health care provided to members. E&O liability coverage protects organizations when allegations of management negligence are made, including the exposure area of vicarious liability, credentialing, peer review, provider selections, utilization review and claims processing. All managed care organizations – from large health plans to small medical groups performing credentialing or utilization review for managed care plans – should have E&O coverage.

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Transplant Management Programs

The volume of solid organ and bone marrow transplants has doubled in the past ten years, and the number of people on waiting lists has tripled. With advances in medical technology and immunosuppressant drugs, the rate of transplants is expected to increase significantly. According to the Centers for Disease Control, the increasing incidence of Hepatitis C alone is expected to increase demand for liver transplants by 500 % by 2008.

 

Managed Transplant Insurance
A comprehensive carve-out program converts this unpredictable and catastrophic risk to a flat monthly cost, allowing payors to budget for claims evenly throughout the year. Additionally, cash-flow advantages may occur as reinsurance recoveries from transplant claims are eliminated. This is typically a first dollar coverage with no deductible, but we can tailor the program to meet individual needs, specific procedures, limitations, out-of-network benefits and specific hospitals.

Transplant Programs & Networks
With an average claim cost of more than $300,000, the increased frequency of transplants can quickly become a catastrophic expense for most organizations. We can provide an innovative transplant program that can help reduce costs, increase productivity and reduce access fees. Our programs provide access to nationally-recognized centers of excellence.

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Neonatal Management Services

Every year, 400,000 fragile infants are treated at Neonatal Intensive Care Units (NICUs) throughout the United States. At each facility, skilled professionals employ the technology and techniques they believe will lead to the best outcome for their tiny patients. But with rapid innovations in diagnostic and therapeutic care, not all medical teams can keep abreast of the latest advancements. In addition, the long lengths of stay can jeopardize continuity of care because of changes in physicians, nurses, case management and UR staff. Evergreen Re’s Neonatal Management Program offers a full range of services – from a comprehensive one-stop resource for the development and enhancement of ‘in-house” case management of neonates and a virtual NICU team to complete transfer of case management to a NICU specialty team for the most difficult neonates.

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NeonatalConsult.com

NeonatalConsult.com is our proprietary web-based site designed to provide health plans with an easy to use comprehensive resource for case managing high risk infants.  Clinical pathway guidelines for specific neonatal diagnosis, statistics, checklists and family resources and handouts are all available to case managers to proactively assist them throughout the entire process.

Created by neonatologists, neonatal nurse practitioners and other healthcare professionals, NeonatalConsult.com is a tool currently used by local, regional and national health plans representing more than eight million covered lives. NeonatalConsult.com features include:

  • Easy to use web-based format
  • Clinical pathways for over 60 diagnoses
  • Clinical Information on syndromes
  • Guidelines on levels of care
  • Discharge planning checklists
  • Post-discharge planning checklists
  • Case Manager tools and resources
  • Family handouts
  • Clinical references

With 30 percent of all NICU discharges delayed for non-medical reasons, NeonatalConsult.com provides clinically aligned conduct of care guidance tools to identify key transition milestones in care, including preparing the home and parents before discharge to avoid unnecessary delays, and post discharge follow-up care to significantly decrease readmission rates.

Most importantly, NeonatalConsult.com assures health plans with standardized, clinically sound set of algorithms when a client has multiple case managers focused on neonatology where errors of commission or errors of omission in the management of these infants could have significant consequences.

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Evergreen Rx - Pharmacy Benefits Management Consulting

Checking Your Vital Signs

With all the innovative drugs, expensive pharmaceutical therapies and new technologies available today, are you confident your pharmacy costs won’t spiral out of control?

Is someone auditing your pharmacy costs to make sure the right people are getting the right drugs at the right costs?

Is your group getting back all the manufacturer’s discounts that represent thousands of dollars to your bottom line?

If you answer no to all or any of the above, you are not alone. Evergreen Re can help you find a precise solution to help you control pharmacy costs.Evergreen Rx PBM Process Guarantees Significant Savings

Evergreen Rx, the pharmacy practice of Evergreen Re, uses proprietary analytical tools designed to help clients evaluate their current Pharmacy Benefit Management (PBM), compare it with other plans, as well as review contract compliance and billing errors. This PBM vendor management process can help clients save 8-13% of gross pharmacy costs and has become a powerful negotiating tool at PBM renewal time.

High-Cost Biologics & Pharmaceuticals
Typically chronic disease patients make up less than 1% of your health plan members, yet they represent 25-30% of pharmacy costs. With more than 100 biotech products currently available and hundreds more in the pipeline, we have identified three areas that payors can save money and protect their bottom line by better management of these high-cost therapies:

  • Lower prices on biologics and injectible drugs
  • Paying only for the drugs used, with no over purchasing due to lot requirements
  • Early intervention, adherence to therapy and prevention of complications involving quality of patient care
  • Last year a health plan responsible for 85,000 lives realized a savings of $640,150 or more than 27.7% of their chronic disease pharmaceutical costs by using this specialty biologics and injectible drugs program.


Prescription Drug Event (PDE) Support for Medicare Part D

The Prescription Drug Event (PDE) process, created by CMS with the introduction of Medicare Part D, is a financial reconciliation process to document and validatethe appropriate use of Medicare dollars administered by a health plan for its drug benefit.

There are many idiosyncrasies with the generation of PDE records, all of which may lead to errors or rejections by CMS, which increases financial exposure to a health plan. Below is a summary of the process and several of the common difficulties are identified below as well as a range of services Evergreen Rx provideshealth plans with this process.

1. Procedure Summary

The PDE record was unheard of prior to the Medicare Part D legislation and the private industry did not have an infrastructure to support

  • Each PBM has built a proprietary process to generate PDE records, which entails the summarizing of claims experience and the generation of new data elements per CMS guidance

  • The PDE processes, although proprietary, need to possess a level of interoperability as beneficiaries can change health plans and PBMs throughout the benefit year

  • PBMs hav\e varied success on accurate generation, and more importantly correction, of PDE records; rejection rates vary between 1% to 15+

2. Common Difficulties

  • Only one PDE record is to exist for a claim experience; if a prescription is filled, reversed by a pharmacy, then re filled, this must be reduced to one PDE

  • As a beneficiaries eligibility changes, perhaps a LICS level and/or a plan change, PDE records must be retroactively modified to the effective date, including all PDEs following that effective date; this has significant potential for errors in calculations

  • Beneficiaries that hold secondary coverage, often through state “wrap” programs, need PDE records to accurately reflect primary and secondary payments

  • Claims that occur upon entering the donut hole and exiting the donut hole to catastrophic coverage are titled bridge claims; these claims must be fragmented into a pre and post payment scheme dependent on which side of the donut hole the benefits dollars are drawing from; the sequence of multiple claims submitted and hence sequence of PDEs generated will determine exactly when the bridge claim occurs

Evergreen Rx provides support for Prescription Drug Events (PDE) Medicare Part D including the following services:

1. PDE Reconciliation

Frequency

  • End of benefit year processing

Description

  • A review of all claims experience from PBM and PDE records submitted to CMS for the benefit year to validate and “tie-out” the claim experience and financial liabilities

  • Reconciles and provides reporting to minimize financial exposure due to errors from CMS year-end response files, including prioritization of errors to be corrected and subsequent evaluation of re-submissions to diminish rejection rate

2. PDE Creation and Submission

Frequency

  • A monthly process of generating and submitting PDE records to CMS

Description

  • “Carves-out” the PDE procedures from PBM claims adjudication system

  • Claim files taken from PBM, PDE records generated, submitted and response files reviewed

  • Included monthly audit and reporting package to track PDE progress

3. PDE Auditing and Monthly Reporting

Frequency

  • Monthly analysis, report and interpretation of both PDE records submitted to CMS and the CMS response files to the PDE submission

Description

  • A validation of PDE submissions and prioritization of errors needing correction; based on best financial return

  • The analysis provides reports summarizing accepted and rejected PDE records, rejection details and additional reports focused on LICS rejections and Part D non-covered drug rejections

4. PDE Calculations Review

Frequency

  • One-time testing procedure of PDE engine

  • More frequent tests may be warranted if the organization generating the PDE records is making changes to PDE programming logic

Description

  • A quality check and balance of a PBM’s PDE processing engine

  • A sample review of PDE records to determine if the financial fields required to be reported to CMS are calculated correctly using most current CMS guidance

View pdf »

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Disease Management

Evergreen Re offers clients a special program designed to control costs and manage Cardiac Disease, a health problem affecting 1 million Americans, with 400,000 new cases every year.

With nearly $107 billion spent on cancer treatment each year, we also offer an Oncology Management program to assist you in increasing patient satisfaction while helping to reduce unnecessary and redundant costs.

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Disputed Claim Management

Through a unique program that automates, standardizes and recovers disputed claims promptly and efficiently, Evergreen Re can help you improve cash flow, reduce cost of managing disputed claims, improve days in accounts receivables and decrease administrative time and costs.

The disputed claim management solution can:

  • Handle large volumes of denied and disputed claims without any additional staffing
  • Process balance due accounts to all insurance plans in all states, in all lines of business
  • Handle escalations of denied claims through the entire appeals cycle
  • Generate significant return on investment dollars, improving cash flow and making better use of A/R staff
    • 40-70 percent recovery rate for claims aged 45-120 days
    • 20-25 percent recovery rate for claims 120 + days

  • Empower you're a/R department to exercise your appeal rights and take control of the appeal process
  • Reduce the red tape and significant administrative costs associated with filing disputed claims
  • Provide the most cost effective way to maximize your account receivables

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Hospital Demand Forecasting

Working with one of the country's leading actuarial firms, Evergreen Re can provide hospital planners sophisticated tools to help map out future utilization and needs in the community in which it operates.

Using a combination of market census and healthcare utilization rates, the tool gives hospitals valuable information to guide the business in the proper direction.

Demand Forecasting projects:

  • Future demand for hospital services by defined geographic markets
  • Utilization forecasts that incorporate new technologies and treatments
  • Quantification of a hospital's current market share
  • Forecasts of market share based on proposed changes
  • Revenue impact caused by changing market share, by individual service lines
  • Capital investment and strategic action required

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Advocacy -- We Work For You

At Evergreen Re we represent the interest of our clients first and foremost. Whether your needs are for reinsurance or any of our other products and services, we become your advocate and work with you to make sure you have the right type and right level of coverage at the lowest total net cost. Once we market your risk and place your insurance, our goal is to make sure you thoroughly understand your coverage, and use it to your advantage.

We not only conduct a comprehensive installation and training program, but will also help you prepare monthly reports, advocating your position on difficult claims and following up with the insurer to get your claims paid within 30-45 days, twice as fast as the industry average of roughly 90 days. Bottom line, we provide clients significant cash flow advantages resulting from timely reimbursements.

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Other Solutions

Finite Reinsurance, Treaty and Quota Share, Captives and Risk , Retention, Oncology Management and Risk, Cardiovascular Disease Management, Specialty Care Networks, Surety Bond, Client Advocacy Services, Claims and Business Process Outsourcing, Claims Audits, Data Driven Services, TPA Outsourcing, PPO and Indemnity Issuing Carrier , Subrogation and other Third Party Liability , Fraud & Abuse Programs.

 

 

   

 

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