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
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
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.