Wednesday, March 11, 2015

Enterprise Risk Management, Claim Settlement and Healthcare News

Enterprise Risk Management (ERM) – Risk Profile Development – Analyze the Risks

Last month we described how to identify the risks organizations face, and how to create a framework for analyzing, measuring and managing them. In this next article of the series, we will explore how to analyze the organizational risks that have been identified. Read more >> http://www.blackburngroup.com/homepage-latest-news/enterprise-risk-management-erm-risk-profile-development-analyze-the-risks

Excerpts from our e-newsletter for Enterprise Risk Management, Claim Settlement and Healthcare Solutions.

Claim Settlement, Medicare, and Medicare Set Asides

The Centers for Medicare and Medicaid Services (CMS) Will Start Using New Life Tables Beginning April 1, 2015. 

Centers for Medicare and Medicaid Services (CMS) Issues Final Rule for Medicare Secondary Payer Determinations. 

Centers for Medicare and Medicaid Services (CMS) Offers an International Classification of Diseases (ICD) 10 Resource Website.

Read more >>  http://www.msariskpro.com/newsletters/march-2015

Healthcare - Patient-Centered Outcomes Research Institute (PCORI) – Has the Time Come for an Expanded Mandate?

Under the Affordable Care Act (ACA), Congress took a step to create a source of trustworthy and understandable information about the costs and benefits of pharmaceuticals and other types of care. By creating the Patient-Centered Outcomes Research Institute (PCORI), Congress funded a research organization that specifically examines the comparative effectiveness of alternative therapies of all types.

Read more >> http://www.blackburngroup.com/riskpro-news/patient-centered-outcomes-research-institute-pcori-has-the-time-come-for-an-expanded-mandate

Tuesday, February 10, 2015

Enterprise Risk Management (ERM) – Risk Profile Development – Identification of the Risks

A few months ago, we described the optimal Context of Risk Profile Development. This article in the series describes how to identify the risks organizations face, and how to create a framework for analyzing, measuring and managing them.

Even within an organizational culture of openness, flexibility and “ownership”, identifying risks and creating structures to measure and manage them are some of the most difficult tasks to undertake. Why? Because any threat to the current or future continuity and profitability of the organization requires the owners to address the risks immediately, and to determine the root causes and conditions of the situations. This takes time and specialized tools, many of which are not readily available.

It’s harder as organizations grow, when they tend to take on the personalities of the individuals and managers who are tasked with organizational stewardship. If the responsible persons have an “ownership” mindset, and are dedicated to preserve, protect and enhance the organizational value, the organization will embrace risks and flourish. To identify risks for profiling, the best place to start is to understand any significant threat to the mission, values and profitability of the organization.

To illustrate an Enterprise Risk Management example, let’s use Apple Inc.’s recent threat to its mobile business from Android devices. The mission statement of Apple recently reported on their website is “Apple designs and creates the iPhone, iPad, Mac notebooks and desktop computers, iOS 8, OS X, iPod and iTunes, and the new Apple Watch.” A risk to having this mission flourish has been the competitive pressures of Samsung’s Galaxy line of cell phones. As soon as the Galaxy line came out and gained rave reviews from analysts and consumers, Apple went to the drawing board to create the iPhone 6 and 6 Plus series. With enhancements and integration of the entire iPhone platform to meet what consumers wanted and needed for their everyday use, the company embraced the competitive risks and has consequently flourished around the world. As a measure of the results, Apple has just reported the largest quarterly profit success of any corporation, $18 Billion, largely based upon the reengineering and success of its new line of phones.

To demonstrate a traditional operational risk identification process, let’s use a Workers Compensation insurance (and self-insurance) example. Because these increasing labor-related costs are a significant threat to most organizations profitability, it requires the owners and managers to address the risks immediately with each occurrence. The past way of looking at identifying these risks has been to gather all of the information once per year (insurance policy, new operational details, claims history, loss control and safety procedures, etc.), ship the stack of paper or electronic files off to the broker, have the broker market the risks, and then hope for a few quotes that don’t break the bank for the renewal. Does this sound like your normal risk identification process? Is this what you are employing now?

Perhaps a better way to identify risk costs is to understand the components of your work force, how each segment contributes to your unique Workers Compensation Risk Profile, and how your unique composition compares to other companies in your industry. As you may know, there is an established industry premium rate history built around individual classes of workers, measured by the classification payroll. Once you calculate your unique composition, it is a relatively easy step to determine how your composition compares to your industry.

The big differences between companies within industries are the way in which they predict and execute strategies to reduce and eliminate claims.  The most severe actual or predicted chronic and legacy claims generally represent 5% of the frequency of occurrences. However, these claims represent 40-60% of the costs of the Workers Compensation Risk Profile. The remainder of the costs of the Risk Profile is administration (management, loss control, actuarial, etc.), allocated costs (adjustment, legal expenses, etc.) and single non-recurring expenses such as minor accidents where the persons return to work immediately.

By utilizing predictive analytical tools and professional services that identify excess costs for each existing or future chronic or legacy claim, the organization can ultimately reduce Risk Profile costs by 20-40%. Is this approach something you would like to consider employing in your organization? Call us to learn more about our products and services.

The next subject in our series will address the Risk Profile Analysis phase…so stay tuned for how to analyze Risk Profiles once you have identified the key components.

Tuesday, January 27, 2015

Enterprise Risk Management (ERM) – 2015 Goals and Strategies

Have you asked yourself how you are going to influence your ERM program for success in the coming year? There are 5 questions that you should ask yourself and your team to eliminate and mitigate key risks with the objective of driving earnings and asset value improvements for your organization.

As a leader of your organization, you are likely trying to catch up from the Holidays and figure out how to guide everyone to produce outstanding results for the coming year. As part of that planning, there are five key questions to consider for mitigating and eliminating risk costs.

Click here to read more >> http://www.blackburngroup.com/homepage-latest-news/enterprise-risk-management-erm-2015-goals-and-strategies

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 rblackburn@blackburngroup.com .