Review of Plan Documents
Each plan document is reviewed for accuracy to ensure eligibility rules are being correctly applied and claims are being paid accurately. We will redraft (if necessary), update and maintain ACA compliant summary plan descriptions (SPDs) and summaries of benefits and coverage (SBC).
Assessment of Staff
Review of organizational structure to align resources, processes and job descriptions. Provide staff development/ training. Assist in recruiting/vetting staff when necessary.
Policies and Procedures
Identify elegant solutions and work/training aides for internal processes; work with supervisory staff to consistently communicate procedure to staff. Maintain P&P manual.
Assist in developing reporting tools to monitor plan and staff performance in a meaningful way. Identify industry benchmarks to comparatively inform Trustees on whether Fund is performing to expectation. Perform claim audits to include pharmacy, dialysis, implantable devices, J-codes. Perform annual reviews, reserve calculations, rate calculations and ad hoc reporting, as needed.
Projections and Plan Designs
Create heuristic predictive models for the purpose of pricing plan designs by reviewing future revenue and expenses. Model tracks historical data and predicts future income statement results, terminal liability obligations, and reserve requirements.
Review of vendor contracts to ensure they are meeting or exceeding expectations and HIPAA compliant by maintaining a current contract and BAA database. Coordinate vendors with overlapping responsibilities. Handle requests for proposal, renewals for organizations like:
• Utilization Review Companies
• Pharmacy Benefit Managers
• Dental Plans
• Vision Plans
• Life & Disability Carriers
Need Assessment for Excess Loss Protection
Determine need for stop loss insurance and identify the appropriate level of coverage. If procured, maintain reporting responsibilities on behalf of client including 50% notification, trigger diagnosis, large case management and disclosure notifications.
Assist in developing solutions with existing platforms to monitor/track eligibility, appeals, and grievances. Assist in complying with new HIPD requirements and health care reform appeal timelines.
Provide information on areas of compliance, tax obligations, and subsidy opportunities.
Development of communication pieces to various constituencies on an as needed basis.
Work cooperatively and collegially with other Fund professionals.
Attend Trustee meetings and assist the Plan Administrator’s efforts to develop a strategic plan.