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. 

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. 

To learn more about Hanover Stone Partners, click here  >>

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.

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.

 
By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc.
                                      
Contact Bob at rblackburn@blackburngroup.com .

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 >> http://www.msariskpro.com/features

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.

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.