Customized Risk-Transfer Solutions Enhanced with Renal Claim Defense


The Problem:

End Stage Renal Disease (ESRD) has increased in both incidence and severity over the last several years and is quickly emerging as the largest disease treatment concern for employers, both self-funded and fully insured.  According to the most recent data, over $42 billion was spent on dialysis for almost 970,000 people with ESRD. With an aging population and a growing diabetes epidemic, ESRD will present an even greater burden to self-funded plans. And that burden may only grow: while Medicare has traditionally been the primary insurer after 33 months of treatment, there is discussion of increasing that threshold to 42 months. This potential cost shifting would only exacerbate an already growing financial concern for businesses

The Solution:

In response to this, Specialty Care Management (SCM) has developed customized solutions to manage renal dialysis treatment costs across the nation. Along with licensed and highly rated partners, SCM can transfer the risk of existing, imminent, and unknown dialysis claims for a specific premium.  Our two major products are a stop-loss option for employer groups and a reinsurance option for insured blocks of business, HMOs, ACOs, and other at-risk entities. Our SCM prescribed protocols are tailored to specific client needs and are priced accordingly.

Our stop loss options, for instance, allow us to match an employer’s risk appetite, as the attachment point for a given claim can be the existing stop loss specific or lower (minimum of $10,000 specific).  This is particularly advantageous when the employer has a relatively high specific; for example, $75,000 or greater.  Our solution: 1) provides savings not only within one’s retention but can limit or avoid lasers or severely increased premiums, 2) where applicable, allows for the negotiation of a rate credit from the existing stop loss carrier and 3) positively impacts the aggregate claim funding level.

As is customary, a premium is based on the age/gender and area distribution of the group’s population.  An adjustment will be made for the relative health status of the population and any known dialysis patients or those identified by underwriting as having a high likelihood of requiring dialysis.  The patients are currently on (or near) receiving dialysis and are either in the coordination period or the elimination period for Medicare to apply.

The reinsurance option for insured blocks of business is available either on the entire population (known and unknown exposures) or on specific identified known claims or emerging claims. The SCM process must also be installed on these individuals, or on the entire population if that scope is chosen. Where the entire block of business is subject to reinsurance, adequate underwriting information must be available to run a proprietary actuarial model, and a clinical analysis of the population (depending upon size we may rely on a sampling), will be undertaken. A monthly premium per covered life will be calculated and remain in effect for the reinsurance period regardless of the number of dialysis claims that emerge.  Renewals are guaranteed until the individual is Medicare primary with rates subject to change on anniversary. For individual dialysis claimants, a premium will be calculated on a “case rate” basis and paid monthly. The individuals reinsured will be identified on a monthly bordereau.

SCM as Your Strategic Partner:

Risk-transfer with SCM is not only financially sensible, but also hassle free.  Along with risk, balance billing and other “leakage” problems are transferred by SCM’s solutions. Under our risk-transfer products, SCM manages the front end analysis and underwriting of plan document and PPO contracts; oversees Medicare eligibility process; verifies that no single case negotiation has occurred; reviews current billing by vendor; determines Medicare allowable from the database; and conducts all other procedural matters to quantify appropriate reimbursement level for the duration requested.  SCM handles appeals and other claim issues, excepting the administrative handling of funds and financial underwriting, which is under the auspices of a nationally licensed Managing General Underwriter. Our Renal Claim Defense (RCD) program enhances our renal carve out product by completely eliminating the risk of and exposure to any legal and extraneous medical costs (outside actual, payable medical expenses) as defined by the benefit plan itself and applicable law. 

As always, SCM constructs premium terms and conditions to ensure long-term relationships and recognition of results for each reinsurance program. Allow SCM to be your strategic partner in managing the catastrophic costs associated with renal dialysis, and we will build a lasting relationship that maximizes your plan dollars.