Case studies from The Assist Group

The Assist Group specializes in solutions for catastrophic claims management and high-risk premature infants. Current products include CareAssist, a unique, physician-driven neonatal care management program, and ClinAssist, a powerful forensic audit and claims resolution service. The Assist Group has a proven track record for delivering financial value to clients. For more information about these products and services, please visit the company's website, www.assistgroup.com, or contact Debbie Stubbs, RN, MS, CCM at Summit Re, 260-407-3979.

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CareAssist Success Story: 32 % Reduction in Length of Stay and $163,693 Savings

This twin boy was born at 25 weeks, weighing one pound, eight ounces. His mother used multiple illicit drugs throughout her pregnancy and on the day of delivery. He was on mechanical ventilation and in critical condition when referred to CareAssist on day of life (DOL) 17. This infant was not expected to survive due to his prenatal history, the circumstances of his birth, and extreme prematurity. The CareAssist neonatologist recommended an ethics committee consultation to discuss quality of life issues when it became evident on DOL 30 that he would survive. By then, this infant had the severest form of intraventricular hemorrhage, along with hydrocephaly and porencephaly. He also had severe chronic lung disease (CLD) and remained on mechanical ventilation well past his first month of life. His long-term prognosis was poor.

His final discharge disposition further complicated his clinical status as his mother continued to struggle with polydrug abuse and was considered unsuitable to care for him after discharge. CareAssist consistently recommended early discharge planning to allow a foster family to be trained to care for this infant upon discharge. This timely intervention allowed this baby boy to be discharged appropriately and safely.

Multiple oxygen weaning recommendations were made by the CareAssist neonatologist. This infant was eventually weaned to nasal cannula oxygen on DOL 59 and was discharged on low flow nasal cannula oxygen. This infant’s nutritional status was complicated by his CLD and tendency to tire during feedings secondary to his compromised pulmonary status. The steroids used to help wean him from supplemental oxygen also compromised his ability to gain weight. The CareAssist neonatologist emphasized to the treating team the importance of using high calorie formula and advised early developmental interventions through the use of non-nutritive sucking and OT/PT involvement in nipple training. As a result of these interventions, the infant was nippling all of his feedings at a corrected age of just 35 weeks.

The weekly care oversight by CareAssist for nearly three months ensured consistency in the implementation of this infant’s treatment plan. Due to CareAssist’s oversight, this infant was discharged safely to foster care 39 days earlier than originally anticipated. This resulted in a 32% savings of $163,693.

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ClinAssist Success Story: $321,757 Savings

A 110-day confinement at a children’s hospital resulted in total billed charges of $1,287,027. ClinAssist reviewed approximately 10,600 line items of detailed charges. Utilizing the clinical expertise of ClinAssist’s neonatologists and nurses, ClinAssist performed a forensic review of the charges and identified the following exceptions:

• Room and board charges billed at incorrect levels of acuity
• Experimental pharmaceutical therapies
• Supplies and services incorrectly unbundled from the room and board charges

ClinAssist successfully achieved a $321,757 reduction in billed charges after the audit exceptions were presented to the facility. The account balance was adjusted to reflect the facility’s written agreement that the exceptions identified by ClinAssist were not payable charges.

Cost containment and more

Summit Re recently entered into an agreement with National Care Network (NCN) for its medical cost containment services. NCN’s core solutions for out-of-network claims include Fee Negotiations, Supplemental Network Repricing, and Hospital Detail Analysis, a Medicare-based pricing methodology.

Unmet Needs

While NCN had been extremely successful in saving its clients millions of dollars with these products, it realized that neither NCN nor other cost containment companies were doing enough to reduce overall healthcare charges. A new product was needed, a product which would:

• Allow fair reimbursement based on the facility’s costs to provide care
• Benchmark similar facilities reflecting the variances within facility costs
• Use flexible pricing methods to meet clients’ needs
• Recommend pricing that is transparent to the payer, provider and member

Data iSight

After a year and a half in development with Data Advantage, a company NCN acquired in 2005, NCN recently introduced Data iSight to meet all of those needs. Data iSight will generate fair reimbursement recommendations that generate legitimate savings. To do this, Data iSight leverages nationally recognized data sets to enhance provider understanding and acceptance; reviews both the financial and clinical components of a claim; incorporates cost-based awareness; and provides a transparency component for providers, payers and members.

About NCN

NCN, a privately held organization based in Irving, Texas, provides its services to large insurance carriers, self-funded organizations, third party administrators, HMOs, employer groups and reinsurance carriers across the country. NCN has achieved many milestones in its fourteen years of operation, including being the first in its industry to receive the URAC Core Accreditation, establishing HIPAA compliant EDI transactions, developing on-line tools for client access of claim tracking and reporting, and reviewing billions of dollars in medical charges.

NCN provides you with a dedicated team to ensure success in helping you meet your savings objectives. Visit NCN at its website, www.nationalcarenetwork.com, or contact Debbie Stubbs, RN, MS, CCM at Summit Re, 260-407-3979.

Getting your D&O and E&O money’s worth

Maybe you are, but then again, maybe you’re not. Errors and omissions (E&O) policies cover things a company does, a company does not do, or that don’t turn out as a customer expected. Directors and officers (D&O) insurance policies provide protection for a company’s directors and officers whose personal financial assets can be put at risk in the event of a lawsuit. There are no standard D&O/E&O policies. Each insurer drafts its own version, and many fail to provide coverage in key areas. If the unfortunate happens and you become the target of a lawsuit, you don’t want to risk losing precious corporate – or personal – financial resources because of inadequate or inappropriate insurance coverage.

As part of our continuing effort to find ways to service you, Summit Re has entered into an arrangement with a national firm that specializes in property and casualty insurance products that are designed for organizations in the health care industry. This alliance was formed to help health plans gain access to better D&O and E&O policies. As part of this arrangement, we are able to offer you a complimentary analysis of your current coverage. A recent study showed that over 50% of directors and officers requested changes in their insurance coverage when they learned what was NOT covered under their current programs.

To perform the analysis, we will need copies of your current D&O/E&O policies. We will determine if we can improve the coverage – and maybe even the pricing. Please contact your Summit Re representative to begin the process.

But what if you have no transplant contract?

Most health plans have contracts with hospitals or medical centers that perform organ and tissue transplants. And, through Summit Re, clients have access to U.R.N.’s Transplant Resource Networks and Transplant Access Program. Most reinsurance agreements provide more favorable coverage for organ and tissue transplants performed in “approved” facilities than for those performed in "unapproved" facilities. The health plan typically submits its contracted rates to the reinsurer during the underwriting process and the reinsurer determines if the contracts will be “approved” or not.

Standard approach

At Summit Re/Swiss Re, that’s our standard approach as well. We usually provide 90% coinsurance for approved contracts (we use the term “scheduled”) and 50% or 60% for unapproved or unscheduled contracts. We list the scheduled contracts on Exhibit A, part of our reinsurance agreement. We consider U.R.N.’s transplant network facility contracts to be scheduled. Usually those contracts our clients hold directly are also scheduled if they are similar to U.R.N.’s.

A potential problem

But what if a member needs to go to a facility that isn’t part of U.R.N.’s network and with which the health plan has no contract for transplants? When the plan tries to negotiate a rate for that member, how will the plan know how the reinsurer will view the arrangement?

Usually the plan won’t know unless the terms are submitted to the reinsurer for review in advance of the transplant, each and every time such a situation arises. This can be frustrating for the health plan and means additional work for the reinsurer.

Summit’s solution

At Summit Re, we recognized this issue early on and took steps to make things easier for you. We developed another exhibit, Exhibit B, which helps our clients determine their reinsurance overage for unscheduled transplants up front.

We list specific case rates we consider to be scheduled for each type of transplant. We show rates for inpatient hospital services only and rates that include professional services. We show a separate set of rates for children and a set for adults. We include rates for all three types of bone marrow/stem cell transplants – even those performed on an outpatient basis.

If the health plan can negotiate case rates that are equal to or are better than the ones shown on Exhibit B, then the claim is reimbursed at the higher coinsurance level. There’s no need to send anything to us for “approval.” You already know the level of coinsurance that applies.

Not a cap

There’s one more very important point to remember, though. The rates listed on Exhibit B do not represent limits on what we consider to be eligible amounts under the reinsurance agreement.  They do not represent caps on case rates. Amounts in excess of the listed case rates are not excluded. If a health plan simply can’t negotiate a rate that is equal to or lower than the Exhibit B rate, it just means the claim would be reimbursed at the lower coinsurance level.

This is just another example of Summit Re’s putting into practice its “fairness” Founding Principle to produce balance sheet stability for you.

What are you, Summit Re?

“What is Summit Re, a broker?” ask some individuals in the industry who haven’t worked with us before. Technically, we are regulated as a Reinsurance Intermediary Broker, which is very different from the retail broker you may have dealt with before. We place reinsurance for health plans, but only for ERC/Swiss Re. And we do so much more: we’re responsible for underwriting each risk, developing and maintaining underwriting and pricing manuals, drafting contracts, processing claims and premium payments, servicing accounts, and maintaining managed care vendor relationships.

The health plan reinsurance marketplace is divided roughly in half between coverages that are delivered directly, which is the way we do business, and those placed through brokers. Which is better? Competition keeps all of us on our toes, but here are reasons we prefer direct distribution.

Deal directly with the decision-makers

Your Summit account team doesn’t just sell a coverage, it prepares and delivers the contract language, pays claims under that contract, and works with your medical management team to reduce current and future medical expenses.

Short distribution chain, low expenses

ERC/Swiss Re retains the risks it writes, so there are no back-end pool and intermediary expenses. Summit provides home office services and sales at a cost comparable to broker loads alone.

It’s a technical sale—we’re a technical company

Summit Re has 3 FSA-level actuaries and 2 CPAs that get involved in your coverage issues. We can tell you we cover LTAC days as standard inpatient days, not restricted step-down days—and be sure we pay the claims that way. Our sales cycle starts with understanding your risk, not just quoting on your current coverage.

Do you work with a retail broker today? You can still get a Summit Re quote. We compete with traditional brokers every day. The broker field is extremely competitive, but the number of reinsurers they have access to is not very large. And that list doesn’t include the largest— Swiss Re, only available through Summit Re.

Managing Your Risk the Summit Re Way

The world is full of risks. These risks present opportunities and, if managed properly, rewards. Summit Re can help you understand the risk, follow the risk, capitalize on the opportunity and reap the rewards of properly managed opportunities.

Founding Principles

Summit Re was founded on four main principles:

1. Practice consistent and fair underwriting which will produce a profit for our reinsurer and balance sheet stability for our customers.
2. Deliver benchmark customer service at effective expense levels.
3. Offer value-added managed care programs to complement those of our clients, particularly in high cost areas such as organ transplants, traumas and low birth weight babies.
4. Provide products and services to assist managed care customers desiring to expand into other fully insured PPO/Point of Service/Out-of-Area programs and employer stop loss programs.

Summit Re can help you design and implement solutions to satisfy your risk management needs. You’ll see that we operate on a few simple tenets:

Enthusiasm – be enthusiastic about your job and the ability to make changes and meet customer requirements.

Optimism – be optimistic about the future and your ability to shape it.

Values – live your values. Stand for something. You are what you do.

Putting Service in Service Standards

We set standards for ourselves so you can reap the benefits of timely and accurate service. Our claims and contracts staff prides themselves not only on meeting the service standards, but also consistently exceeding the standards.That means you can rely on timely and accurate service from Summit Re so you can concentrate on your business without worries about your reinsurance.

Swiss Re Purchase of ERC

On June 10, 2006, Employers Reinsurance Corporation (ERC) was acquired by Swiss Re. Both Summit Re and ERC are excited about this business transaction, as it will increase our ability to provide you with the best financial security, expertise and service in the reinsurance industry. The transaction includes all of the Commercial Insurance operations of Employers Reinsurance Corporation. Swiss Re specifically sought to include the HMO reinsurance and employer stop loss product lines in this transaction and has plans to grow the Commercial Insurance operations.

Effective with the closing, the senior management of the Commercial Insurance division of ERC will remain in place, including Robin Sterneck, President, and Jeff Argotsinger, Vice President and medical excess product manager.

ERC, as a part of Swiss Re, will provide our customers with even more customized solutions. As a company focused solely on insurance and reinsurance risk worldwide, Swiss Re recognizes the value of building and growing customer relationships for the long term. Swiss Re is now the world’s largest reinsurance company in both property/casualty and life/health business.

As part of the transaction, General Electric, the former parent of ERC, has acquired 9% of Swiss Re shares and will have a board seat. GE is essentially taking a smaller share in a larger operation.

With this acquisition of ERC, Swiss Re took a strong balance sheet and made it even stronger. ERC is currently rated A by AM Best, and Swiss Re is A+. Below is a summary of the financials of the combined operation (2005 results were not yet available).

Summit Re and ERC have a long term agreement to underwrite catastrophic medical excess reinsurance together. We look forward to the opportunity to provide HMOs and other managed care plans with reinsurance through our exclusive relationship with ERC. Swiss Re management has re-approved our marketing plan, pricing / underwriting manuals and guidelines.

If you have any questions, please feel free to contact your Summit Re Regional Vice President or call Brian Fehlhaber at 260-469-3004.

Best of Both Worlds: Self-Funding and Managed Care

To control the rising costs of providing a medical benefit program, some employers look to self funding. HMOs that can offer administrative services only (ASO) or affiliate with third party administrators (TPAs) can bring both a self-funded approach and managed care programs to employers.

Selecting an MGU

HMOs who participate in the employer stop loss market should carefully select a managing general underwriter (MGU) with expertise in both managed care reinsurance and the self-funded market. Your MGU should also have full-service capabilities. Summit Re is a full-service MGU focusing on HMOs who participate in the employer stop loss market. Our managed care experience sets us apart from traditional employer stop loss carriers and managing underwriters.

Pricing and Underwriting

Summit Re’s staff of underwriters and actuaries is dually equipped to understand this combination of funding and managed care savings. We apply our knowledge in the development of competitive stop loss rates and aggregate funding factors for your self-funded clients. As one of the market leaders in HMO excess reinsurance, we have a unique understanding of HMOs and their excess medical risk. We review not only your provider contracts, but also your managed care protocols and your HMO experience.

Sales Support

Summit Re takes an active role in helping you place self-funded business. We are a phone call away to discuss strategy on individual accounts. In unique situations, we can assist you in the on-site presentation of the stop loss proposal to the employer. Once a group is sold, we focus on servicing the account.

Integrated Administration

Our rating and proposal system is fully integrated with our stop loss contract production, premium collection, and claims payment modules. This results in proposal-based policy issued quickly, accurate premium accounting, and timely claim payments. We also have an experienced staff in each functional area to ensure that personalized service isn’t forgotten.

Risk Transfer Flexibility

Summit Re works with two carriers who provide the employer stop loss product: Companion Life Insurance Company and Presidential Life Insurance Company. These two carriers allow Summit Re to write this product in all 50 states.

If you want to retain some of the risk but do not have an insurance company, there are certain approaches we can use that allow you to assume a portion of the risk written by one of our insurance company partners and managed by Summit Re.

If you have an insurance company to write the employer stop loss product, your carrier can keep some or all of the risk. Summit Re can provide some or all of the MGU services, or your insurance company can perform all the functions with Summit Re providing consulting services in specific areas.

Summit Re’s goal is to be creative, responsive and entrepreneurial, to help you meet your strategic goals for employer stop loss, whatever they may be!

Clinical Notification Triggers

The clinical notice form should be used by the medical management staff to notify Summit Re of potential cases where Summit ReSources may be of assistance to you. Use the clinical notification triggers list as a guide. The list is not all inclusive, so feel free to submit a clinical notification on any case for which Summit Re may be of assistance to you.

Diagnosis

• High cost pharmacy, such as Flolan, Factor VII, Factor VIII, Cerezyme / ICD-9: 272.7, 286.0, 415.0, 416.0, 416.8 
• Major burns with a potential for a prolonged hospitalization / ICD-9: 941.0, 942.0, 943.0, 945.0, 948.2-9
• ESRD/dialysis with monthly dialysis costs greater than $10,000 / ICD-9: V56.0, V56.8, V45.1 
• Major injuries or multiple trauma with a potential for a prolonged hospitalization and/or acute rehabilitation admission
• Premature infants with one or more of the following:
  • gestational age ≤ 24 weeks / ICD-9: 765.0 
  • severe congenital heart disease, e.g. hypoplastic left heat, Tetralogy of Fallot, etc. / ICD-9: 746.7, 746.01, 746.89, 745.2
  • severe gastrointestinal anomalies, e.g. gastroschisis, omphalocele, necrotizing enterocolitis, short bowel syndrome, etc. / ICD-9: 756.79, 777.5, 777.8, 579.3, 756.79
  • severe bronchopulmonary dysplasia requiring long term ventilator treatment / ICD-9: 770.7

Case Characteristics

• Out of network services with minimal or no negotiated discounts
• Billed charges that greatly exceed reasonable and customary for the services rendered – refer before the claim is paid
• Questionable charges, such as unbundling or experimental treatments
• Cases with the potential to exceed the reinsurance deductible
• Multiple inpatient stays

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Submission Process for Clinical Notices

1. Use the clinical notification triggers list as a guide for completion of clinical notifications submitted to Summit Re.
2. It is recommended that the clinical notices be submitted from the medical management department as they are usually the department first notified of a request for services.
3. Complete the Clinical Notification Form (all sections that apply to your case).
4. Completed forms may be faxed to 260-469-3014, emailed via encrypted software to claims@summit-re.com, or mailed to Summit Reinsurance Services, 7030 Pointe Inverness Way, Suite 350*, Fort Wayne, IN 46804.
5. In lieu of the clinical notification form, you may submit a report containing similar information.

*Address updated when this article was converted to this post in 2014.