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MANAGED CARE RISK MODELING DECISION SUPPORT


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EXPERIENCE AND QUALIFICATIONS

TIMOTHY M. ROSS, FSA, MAAA

Tim Ross is a consulting health actuary with 20 years of group insurance, managed care, and actuarial experience.  This experience includes over 10 years (1990-2000) with Deloitte & Touche as a Senior Manager in the health actuarial consulting practice in Minneapolis.  Prior to that,  over 9 years (1981-1990) with The Prudential Insurance Company of America as a group underwriter in the Minneapolis regional home office.  Mr. Ross' managed care experience dates to January, 1987, with the provision of book of business underwriting services for Prudential/PruCare operations in the midwest region.  This experience has expanded in breadth and depth in the ensuing 17 years to include services to HMO's, insurers, dental HMO's, hospitals, physician groups, physician-hospital organizations, and state governments across the country, for matters in the commercial, Medicare, and Medicaid markets.
 

Examples of services provided include:

  • Estimation of and certification of claim reserves for Incurred But Not Reported (IBNR) claims.
  • Evaluation of historical trend factors and development of trend assumptions for incurred claim projections.
  • Development of claim cost projections.
  • Analysis and reconciliation of prior claim cost projections by comparison to actual emerging claims.
  • Fee schedule development and analysis.
  • Development and analysis of risk-sharing arrangements to align incentives between physicians, hospitals and the HMO, and risk-modeling and scenario testing of proposed arrangements.
  • Capitation rate development for primary care, specialty care, and global physician services, hospital care, and global capitation arrangements.
  • Development and negotiation/facilitation of physician-hospital groups into Physician Hospital Organizations (PHO's) and assisting PHO's in negotiating financial arrangements with HMO's.
  • Analysis of medical claims data and development of actuarial cost models of utilization and unit costs by health care service category.
  • Use of actuarial cost models to evaluate proposed benefit plans, copayments, and service limitations, as well as the impact of proposed fee schedule changes on capitation and premium levels.
  • Analysis of high cost medical claims and development of claim cost continuance tables to evaluate the risk of high cost claims.
  • Pricing of specific stop-loss insurance and reinsurance for high claim risks.
  • Use of Monte Carlo risk modeling techniques to evaluate the health claims risk with various levels of stop-loss insurance. Combining this with stop-loss cost levels to provide decision support to providers and insurers in selecting the level of stop-loss coverage appropriate to their situation.
  • Development of Medicaid managed care capitation rates for state Medicaid agencies for AFDC/TANF and related populations, disabled, and Title XXI SCHIP programs.
  • Participation in state-HMO rate setting work groups, presentation of rate setting methodologies, and participation in rate negotiations.
  • Assisting state Medicaid agencies with financial projections for waiver program development for SCHIP programs, disabled populations, behavioral health programs, and persons with developmental disabilities.
  • Assisting HMO's in preparing capitation premium rates for competitive rate proposals for the Medicaid managed care program.
  • Assisting provider groups in negotiating capitation rates and risk-sharing arrangements in partnership with an HMO for a competitive Medicaid proposal.
  • Preparing statistical sampling analysis of Medicare/Medicaid claims for a health care system and counsel in response to a HCFA/Attorney General fraud and abuse investigation.
  • Review of HCFA statistical sampling of claims on behalf of a health care system.
  • Development of statistical sampling methodology for an on-going Medicare/Medicaid claims compliance program.
  • Expert witness providing statistical sampling to evaluate contested claims for an HMO.
  • Expert witness providing actuarial information to evaluate and review estimated damages in a medical device patent infringement case.

 

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