HMO's and Insurers
The Medicaid Market
SERVICES FOR MANAGED CARE PROVIDERS
Providers will frequently need the assistance of an experienced health actuary in contracting with managed care organizations. Ross Health Actuarial can assist you in addressing the following needs:
- Understanding non-FFS reimbursement. Many or most managed care contracts pay providers on a basis other than Fee-For-Service. We can help you evaluate and understand compensation proposals.
- Level the Playing Field. The HMO often has the advantage in viewing health care costs on a PMPM basis, and also in having a database of insured experience on the population for the proposed capitation arrangement. Economists refers to this as "Asymmetric information;" we can help level the playing field by negotiating for and analyzing information from the HMO, and supplementing that information with our database.
- Evaluate Risks. Capitated arrangements can present significant risks; we can help you evaluate the risks of outlier cases, as well as reinsurance arrangements or built in stop-loss provisions in the capitation contract.
- Equitable pricing. Is the reduction in capitation reasonable in light of the increase in copays or the stop-loss protection offered? What is the value of adding or deleting specific services from the capitation aggreement? What will happen under the risk-adjustment or risk-sharing arrangement? We can help you to negotiate a fair price.
Specific services include: