Friday, November 7, 2014

RiskPro® Products and Data

Our Suite of Technology Products and Data Provide a Strategic Platform for Your Most Challenging Risk Issues.

All enterprise risk management industry participants rely heavily upon information to perform their roles and to serve their constituents. The delivery of risk management, insurance, and claim solutions require consistent, accurate information be shared confidentially across a large and fragmented industry.

We provide a broad range of general and custom underwriting, claims, and loss control applications and information that support key risk management, casualty, health, and disability insurance transactions. The components of these application suites can be combined and modified, or supplemented with new application components, to provide custom solutions for large, complex, multi-entity business enterprises. Our products and services are deliverd through the RiskPro® Core, RiskPro® Health and MSA RiskPro® brands.

These applications and services are tailored to a clients specific needs, so you may be assured that you will only pay for what you need. We provide twenty-four hour, seven-day-a-week support services for all of our products and services.

Interested in learning more about our products?  Call us at 585-586-4530. 

Thursday, November 6, 2014

How to Improve Your Captive Insurance Company Performance

John J. Kelly, the founder and managing partner of Hanover Stone Partners LLC, has recently written an article published in Property Casualty 360 entitled “5 Steps to Improving Your Captive's Performance”. 
The article offers important information about Clams Management, Reinsurance Strategies, Consolidation or Re-domestication Opportunities, Independent Viewpoints, and Governance. 

Wednesday, November 5, 2014

The Context of Risk Profile Development

All of us practice some form of “risk management” by approaching life’s opportunities and challenges each day in an organized way.  In the context of an enterprise, Risk Profiling is a way to help organize each opportunity and challenge to be measured and managed over time.

To build risk profiles for a company or organization, the best place to start is to understand the mission and values of the organization through it mission statement. For example, the mission statement of Apple Computer after Steve Jobs died has been reported as,

“Apple designs Macs, the best personal computers in the world, along with OS X, iLife, iWork and professional software. Apple leads the digital music revolution with its iPods and iTunes online store. Apple has reinvented the mobile phone with its revolutionary iPhone and App Store, and is defining the future of mobile media and computing devices with iPad.”

During the 1980’s, Steve Jobs reportedly stated Apple’s mission was,

“To make a contribution to the world by making tools for the mind that advance humankind.”

Which statement provides the best context for building Risk Profiles at Apple Computer? They both do, because each mission statement helps to define the context to meet the future opportunities and challenges of the organization.

Therefore, Enterprise Risk Profiling is an organized way to identify, analyze, treat, and monitor challenges to support the organization’s opportunities and values. The primary questions to ask before any effort to create Enterprise Risk Profiles is “Do we have an approach and framework to understand our mission’s opportunities and challenges?” In other words, “How do we maximize our opportunities to create value which include identification, analyses, treatment, and management of risks”?

Each organization is different, but generally it starts with the senior executives and directors clearly articulating the goals and objectives of the organization to maximize value. Thereafter, the organization needs leadership and resources to execute the strategies to achieve the objectives. Within the execution of the strategies, Risk Profiling gains its necessary context.

Tuesday, November 4, 2014

CMS Announces Payment Rules

Last week the Centers for Medicare and Medicaid Services (CMS) announced several payment rules to reward higher quality and lower cost programs, including Medicare Set Asides.

The final rules include Medicare payments to physicians and non-physician practitioners, hospital outpatient departments, ambulatory surgical centers, home health agencies and dialysis facilities that treat patients with end-stage renal disease.
The new CMS rules are an attempt to gain greater value for the healthcare expenses of the system, and are welcomed by the provider and payer communities. Some of the highlights include:

•  Better coordination of care for beneficiaries with multiple chronic conditions. Beginning in 2015, the Medicare Physician Fee Schedule will include a new chronic care management fee. This separate payment for chronic care management will support physician practices in their efforts to coordinate care for Medicare beneficiaries with multiple chronic conditions. Presumably, this should help improve the coordination of care for patients outside of regular office visits.

•  Rewarding value rather than volume. In 2015 Medicare is continuing to phase in the Value-based Payment Modifier, which adjusts traditional Medicare payments to physicians and other eligible professionals based on the quality and cost of care they furnish to beneficiaries. The adjustments translate into payment increases for providers who deliver higher quality care at a better value, while providers who underperform may be subject to a payment reduction.

•  Providing incentives to hospital outpatient departments and facilities to deliver efficient, high-quality care. The Hospital Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS) rule includes opportunities to promote greater packaging of payments for items and services rather than making separate payments for each individual service.

•  Better information for providers and beneficiaries to understand the total scope, cost, and quality of care. To assist physicians in improving quality of care for their Medicare beneficiaries, CMS recently made Quality and Resource Use Reports available. The reports include information about the scope, cost and quality of care that is delivered to the Medicare beneficiaries they serve, both inside and outside of their practices. These reports should improve care coordination and reduce unnecessary services. Also, the Physician Compare website allows consumers to search for information about physicians and other health care professionals who provide Medicare services so they can make informed decisions about who delivers their care.

•  New quality and performance measures for dialysis facilities. The End-Stage Renal Disease (ESRD) Prospective Payment System rule introduces new quality and performance measures for outpatient dialysis facilities. In 2017, a Standardized Readmission Ratio, which assesses the rate at which ESRD dialysis patients return to an acute care hospital within 30 days of discharge from an acute care hospital, will attempt to reduce unnecessary hospital readmissions.

Blackburn Robert 
By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc.
Contact Bob at .

Friday, October 31, 2014

CMS Is Improving Turnaround with Workers’ Compensation (WCMSA) and Liability (LMSA) Medicare Set Asides

Our review of the Centers for Medicare and Medicaid Services (CMS) process has determined that CMS's Worker's Compensation Review Contractor (WCRC) continues to improve its turnaround times. Liability case (LMSAs) approvals are about the same time frame as earlier this year. The approval process is managed directly with the designated CMS Regional Office (RO).

The Approval times on both Workers’ Compensation and Liability cases remains around 30-45 days, assuming there is no requests by either the Worker’s Compensation Review Contractor (WCRC) or the CMS Regional Office (RO) for additional information from the claimant. At the present time there does not appear to be any significant backlog and the review contractor and CMS appear to remain on track in concentrating on new submissions.

For more information click here >>

Accelerated Settlement Solution Engagement - Recent Results

A diverse retail organization with thousands of stores and warehouses worldwide wanted to reduce Workers Compensation and Liability claim costs and improve standardization and control across the enterprise. We helped them in their effort to redesign and implement major improvements in a variety of areas of their risk and claim administration, including risk analytics, litigation management, and financial product services. The result? Tens of millions in annual cost savings – money that could be redirected from Workers Compensation and Liability claim costs to corporate reinvestment and earnings.

The Challenge

The internal risk and claim management department is a small group of experienced and knowledgeable persons with an enormous responsibility of coordinating numerous vendors and operations worldwide to serve in the administration and closure of claims. They have an experienced and capable Third Party Administrator who is providing daily claim administration services. The client provided us detailed loss runs for several years of data. After sorting and benchmarking the claims utilizing models and substantial risk and claim databases, Blackburn was able to organize the priorities of claims across various offices around the world. Our partners and associates focused on the key drivers of costs to determine what was applicable to the claim occurrence, and eliminate any other costs which were not associated with the occurrence. Then, utilizing our technology, products and professional services we were able to help execute closing strategies for all of the prioritized files.

Additionally, we found that our client's attorneys were following a standard process of managing and negotiating the litigation of the claims. With our assistance, the teams were able to interrupt the standard process and move the claim to closure by providing the necessary strategic resources.

How We Helped

During the process of analyzing our client's data, we found that an integrated Accelerated Settlement Solution approach would provide significantly reduced loss costs for individual cases and the programs versus a normal approach.
Additionally, we reviewed the normal timeframe to resolve significant claims, and compared the results with our source data. By employing an Accelerated Settlement Solution approach the teams were able to eliminate 20-25% of the time associated with "open" legacy claims.

The Solutions

After our analysis and with our solutions, the teams employed an integrated, specialized approach to these efforts including:
  • Medical Lien Verification and Negotiation,
  • Accelerated Settlement Medical Cost Projections,
  • Medicare Set-Asides and MMSEA Section 111 Mandatory Data Reporting,
  • Life Care Planning,
  • Structured Settlements,
  • Custodial Account Administration,
  • Special Needs Trust Development, and
  • Associated Financial Planning.
The teams are now utilizing Blackburn predictive models for all new occurrences which alert the entire team to claim loss control. Further, we have helped to eliminate redundant and disconnected analysis, variations in adjuster experience applied to the claim, and a tasked-based approach to the normal litigation services.
By using unique and integrated approaches, and an extensive results-oriented, technology-based benchmarking capability with experienced clinical teams, the final total costs of claims have been reduced by millions of dollars annually.

Wednesday, October 29, 2014

Medicare Set Aside Personal Injury Requirements and Process

Medicare is not responsible for paying a beneficiary's medical expenses for a personal injury when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.”

Under Section 1862 42 U.S.C. §1395y(b)(2) and § 1862(b)(2)(A)(ii) of the Social Security Act, Medicare is not responsible for paying a qualified injured person’s medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.”

If the medical expenses are disputed in a personal injury situation, the provider, physician, or other supplier may bill Medicare as the primary payer. If the product or service is normally reimbursable under Medicare rules, Medicare may pay the expenses conditionally.  Then if there is a subsequent settlement, judgment, award, or other payment, Medicare requires reimbursement of the expenses.

For example, if the beneficiary was injured or became ill on the job, they would establish a Medicare approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).  This amount of money is forecasted as a final amount that must be spent by the beneficiary related to the injury before Medicare makes any payments toward the personal injury settlement.

How does a beneficiary reimburse Medicare?

When a personal injury claim is settled, the Benefits Coordination & Recovery Center (BCRC) issues a formal demand letter advising the beneficiary and their attorney of the primary payment responsibility. They may issue preliminary letters to assist in the settlement process.  These letters include: 1) a summary of conditional payments made by Medicare; 2) the total demand amount; 3) information on applicable waiver and administrative appeal rights. Click here for a flowchart of the Medicare Conditional Payment Recovery Process >>

When the conditional payments have been finally determined and negotiated and the Medicare Set-Aside has been determiined, the beneficiary will receive a letter from Medicare about how to account for the funds. The funding typically is arranged as a Lump Sum or Structured Settlement, depending upon the circumstances of the case.  Quite often, it is best to determine all potential amounts of money as early as possible in the settlement process to avoid confusion and to smoothly resolve the case. 

Tuesday, October 28, 2014

Your Doctor’s Favorite Insurance Companies – The Latest Survey from Over 6,300 Physicians

In a recent survey and study completed by Medscape Multispecialty, a division of WebMD, over 6,300 physicians across the United States rate the best and worst insurance companies. How does your medical team feel about your insurance company?

Doctors and healthcare providers have a “love/hate” relationship with insurance companies. Every time we consult with our clients about “payers” in the system, the healthcare providers bristle about the frustrations they have with insurers, and immediately launch into the latest story about “those idiots”.

The most recent 2014 Medscape Multispecialty survey is very helpful for all industry participants to learn what doctors’ think are the most important things about healthcare finance.

The highlights from the physicians’ survey include:

What qualities are most important in an insurer?

The top three answers are Reimbursement rates, Ease of doing business, and Frequency of denials.

Which insurers do doctors consider the best?

The top four insurers are Blue Plans, Aetna, Cigna, and Harvard Pilgrim Health Plan, however all four insurers rated just slightly over average on a scale of 1-5. The Blues and Aetna were the top two insurers in the 2011 study, and Cigna and Harvard moved up in rankings since 2011.

Which insurers had the fewest denials?

Surprisingly, Medicare was ranked the best, followed by the Blues and Aetna.

Which insurers had the speediest claim payments?

The best insurer was the Blues, followed by Medicare and Aetna.

For more details about the demographics and survey results, visit the most recent 2014 Medscape Multispecialty survey >>

Thursday, October 23, 2014

Medicare Set Aside News - CDC Chronic Disease Indicators

The Centers for Disease Control and Prevention (CDC) Offers Useful Tool for Self Insurers To Benchmark Their Cases and Programs.

The CDC's Chronic Disease Indicators (CDI) is a useful tool of 97 indicators that were developed to allow states, territories and large metropolitan areas to uniformly define, collect, and report chronic disease data that are important to public health practice. Self insurers can use these tools to benchmark their own data for insights and management.
CDI are divided into eight categories that represent a wide spectrum of conditions and risk factors as well as social context:
  • Physical activity and nutrition
  • Tobacco and alcohol use
  • Cancer
  • Cardiovascular disease
  • Diabetes
  • Arthritis
  • Overarching conditions
  • Other diseases and risk factors
For more information about these benchmarking tools for self insured Property, Casualty, Health, and Disabilty programs, please visit the National Center for Chronic Disease Prevention and Health Promotion website.

Wednesday, October 22, 2014

The Drug Enforcement Administration’s (DEA) Reclassification of Hydrocodone Combination Products (HCPs) Affects Healthcare

In August, the U. S. Drug Enforcement Administration (DEA) published the Final Rule moving hydrocodone combination products (HCPs) from Schedule III to the more-restrictive Schedule II status. How will the healthcare and insurance communities respond to this ruling?

For many years, the healthcare and insurance communities have debated the most cost effective ways for treating patient pain from chronic medical conditions. The more restrictive ruling by the DEA will bring a greater focus by physicians and insurers to find alternatives to HCP prescriptions.

Historically, HCPs are the most prescribed medications in America. With 135 million prescriptions filled in 2012, they are prescribed 25 percent more often than the next prescribed medication. For several years, a physician prescription for an HCP medication has resulted in a predictive “flag” for self-insurers and insurers to monitor potential longer term “legacy” or “chronic” claims. For payers, the view is that an HCP prescription has been an easy way for the physician or healthcare provider to satisfy the complaint of a patient’s pain without finding alternative therapies or medications. Healthcare providers will now be forced to consider alternatives with the more restrictive ruling. What options will they be considering?

Some of the best healthcare teams in the country have recognized and utilize a holistic approach to long term case management. For patients and their families, WebMD offers a Pain Management Health Center to become initiated with the symptoms, therapies and medications. Their 11 Tips for Living With Chronic Pain is a helpful guide for patients and their families to learn more about alternatives, with their physician and medical team’s guidance. Other sections in the Pain Management Health Center will provide additional guidance about specific root causes of pain.

Additionally, there are several well-known pain management clinics around the country for consultation with specific needs. Those clinics include The Mayo Clinic’s Pain Rehabilitation Center in Minnesota, The Cleveland Clinic’s Chronic Pain Rehabilitation Program, The Stanford University Pain Management Center, and The Johns Hopkins Blaustein Pain Treatment Center, among others near the patient and their family. Rather than taking medications alone, these and other treatment centers will offer specific tailored pain management approaches to individual needs.
While the consultations are modestly more expensive at the beginning of a treatment plan, over the long term the patients and families are better served with better pain management results. For payers, it may be very cost effective to consider a pain management consultation as soon as a claim “flag” is encountered. Solutions that provide a holistic approach will ultimately lead to better, and fairer, outcomes for the patient and payers.

Tuesday, October 21, 2014

ERM News - Enterprise Risk Management (ERM) and the ICD9 to ICD 10 Conversion

Over the past several years, the healthcare community has been gearing up for conversion of the International Classification of Diseases, Ninth Revision called “ICD-9”, to the Tenth Revision called “ICD-10”. The Centers for Medicare and Medicaid Services (CMS) announced recently that they will be implementing the ICD-10 standards on 10/1/15. So what are organizations doing now?

Over the past several years, the large health insurers have spent millions of dollars testing duplicate systems to ensure a framework of cost neutrality. Providers have done the same for their billing and revenue programs. From what has been observed to date, all industry participants will have a lot of work to accomplish over the next few years to ensure cost neutrality and containment.

So, what are organizations doing now? The focus for ERM programs is to employ dedicated technology and teams to predict and manage legacy and chronic claims during the ICD-9 to ICD-10 conversion.  Why? Because it is generally known that 5% of the claims (legacy and chronic) of any health, disability, or casualty program represents over 50% of the costs. The best way to maintain a "neutral" environment will be to predict, benchmark, and manage these claims utilizing both the ICD-9 and ICD-10 standards until enough institutional experience is gained to have confidence in the new standards.

With an entire industry trying to adopt a "concept of neutrality", many insurers and providers are trying to establish operating environments where they can make decisions about future care and cost management. If you are a corporation, third party adjuster, insurer, actuary, or other participant moving toward the new standards of diagnoses and treatments, what should you be concerned about?

Systems –
o   Do you have ICD-9 and ICD-10 "crossover" systems to see the differences in the diagnoses between the two different standards?
o   Do your systems have adequate granularity to assess clinical modifications and procedural classifications?
o   Are there legacy and chronic "flags" for claims that are being processed at the time of the occurrence or admission?
o   Are your systems addressing the clinical and catastrophe risks in an adequate way to match the risk profiles of all participants?
o   Are wellness programs integrated into the clinical systems to address the frequency and severity risks?

Clinical Personnel –
o   Do you have a data-driven, multi-disciplinary team which monitor and address the predicted legacy and chronic claims at the outset of the occurrence or admission?
o   Are there adequate team and outside resources to address specialty claim risks?
o   Are your resources adept at coordinating care for the duration of the case?
o   Are all team members working together to address appropriate care in a cost effective manner?

Management –
o   Is there a culture of education, training, confidence and support for the team's work?
o   Have the efforts been financed in a way that support a long term vision of cost containment and control?
o   Are all stakeholders committed to understanding and supporting the objectives of the transition project?
o   If and when disagreements arise in the process of reviewing and managing the differences in the standards, is there an expedited adjudication process of decision making so that the claimant or patient is not adversely affected by time delays?