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ROSS HEALTH ACTUARIAL


MANAGED CARE • RISK MODELING • DECISION SUPPORT

 

 

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· 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.

                 

Ross Health Actuarial, 719 Crosby Drive, Hudson, WI  54016

(715) 381-1345  timross@rosshealthactuarial.com

 

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