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.
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.
