Core Services

What We Do

NRA is a leader in Managed Care Reinsurance and as a privately owned and operated firm is one of the largest reinsurance intermediaries and risk consultancy firms in the U.S. As your reinsurance advisor and advocate we offer advanced risk solutions and unique risk management advice relative to the management and placement of health care, property/casualty, bonds and employer group health risks.

Clients include self-funded employers and Managed Care Risk areas (Commercial, Medicare, Medicaid). These include and range from HMOs, ACOs, Providers (hospitals and physicians), DCEs, CINs, state programs, insurance exchanges, associations, unions, PACE, etc.

NRA has assembled an array of core capabilities to support our Managed Care Firms nationally. Health firms will find the needed underwriting ability, actuarial rating tools, actuarial models along with the expertise to problem-solve with HMOs, providers, employers or other licensed risk bearing firms. We do not employ a “cookie-cutter approach” since one-size doesn’t fit all. Rather we let the data reveal the risk and determine what suits a client best.

Whether you represent an HMO, regional insurance company, captive, municipal pool, risk retention group, provider at-risk contracting, ACO or employer we have the ability to design a risk transfer solution. We offer excess of loss reinsurance solutions through several highly rated reinsurance partners. Risk protection is laser tailored to fit the specific operational and financial needs of each client.

Today, medical risk is increasingly complex, costly, and confusing. We are laser focused on creating unique risk solutions and strategies to help clients better prepare, manage, and plan for the risk already on their books. Our deep understanding, crafted over decades of experience, of the healthcare landscape allows us to identify and create advanced risk solutions for certainty vs. uncertainty. Rising risk and costs do not have to be risky but can be defined and prevented to lessen the negative financial impact from RX specialty drugs, emerging procedures such as wound care, gene/cell therapies, and technologies. Thus, our renaissance thinking and avante garde approach lays a foundation against the ever-increasing pace of at-risk contracting and cost-shifting from the payers. Doing the right thing, in the right way for the right reason is not only important but essential to stymieing these risks and generating optimal profits for your long-term success.

Services

1. Actuarial Services from NRA

Managed Care – Actuarial Services include entities such as health insurance plans, HMOs, PPOs, ACOs, Capitated Providers and Self-Funded Employer Groups that contract with healthcare providers to control costs and improve quality.
Reinsurance – This is coordinated with the client’s data, peer groups and industry manual rates to form a rating picture to protect against very large claims or high levels of unexpected loss. Data reveals the risk.
Actuarial Advice – This blends the above two (2) areas into a complete risk profile and net cost analysis using sabermetrics, math, statistics, and financial theory to study and project uncertain and future losses relative to healthcare costs, claims, and reinsurance risks.
IBNR Calculations – We can provide reserving calculations based on accepted actuarial techniques to ensure clients have adequate reserves for any risk-bearing contracts or programs you may have in place.
Shared Savings Audit – Review shared savings calculations to verify accuracy of methodology and calculations. Provide review and evaluation of underlying claims data to ensure appropriate data is being utilized. Ensure alignment with contractual risk obligations.
Contracting Support – Review financial elements of payor contracts to ensure contract terms are reasonable and that any financial incentives provided are measurable and attainable. We will provide ongoing support in tracking performance against these terms to provide an unbiased, independent view of performance.
Reinsurance Negotiations and Pricing – Utilize your historical experience data to pre-underwrite your account to better obtain most favorable rates from the reinsurers. Provide insights into the cost and/or savings of various reinsurance mechanisms and risk contracts on a Net Cost basis to determine the most optimum price points. This may include simple reinsurance contracts whereby risk stratification and analysis are required to ensure the appropriate level of risk (deductible) and cost for the client or include more complex reinsurance structures like captives. Funding options are assessed and considered to maximize Reinsurance Program cost effectiveness.
Provider Payment Allocations – Assess various methodologies to help health firms align payment structure and incentives to providers based on performance.
ROI Measurement – Provide actuarial support to evaluate effectiveness of various reinsurance/risk programs in place to manage cost/risk. This might include case management programs, pharmacy programs or network steerage programs. Our aim is to provide our clients with an unbiased, technically sound view of the various programs they may be using or might be encouraged to use.

NRA’s actuarial analysis incorporates design and reinsurance price points to assess and evaluate the most optimum risk/financial solutions based on actuarial science to protect clients from catastrophic claims, high utilization, or unexpected healthcare costs.

Key Parts Include:

Actuarial Modeling: Estimating expected losses, volatility, tail risk, and helping price reinsurance coverage appropriately.
Managed Care Reinsurance Types: Specific Stop-Loss, Aggregating Spec Deductible, Surplus/IBNR Relief, etc.
Quota Share or Risk Corridors: Sharing a percentage of risk above/below certain targets.

Value – Why It’s Important:

Stabilizes financial results and profits
Identify most optimum funding options

Protects solvency and financial risks
Helps smaller or newer risks manage high-cost volatility
Satisfies regulatory requirements in some cases (e.g., minimum surplus levels).

2. HMO Reinsurance

HMO reinsurance protects the balance sheet against infrequent but catastrophic claims so the profits remain stable without negative cash drain against corporate assets. Reinsurance is bought for specific deductibles using a variety of funding methods that matches risk to corporate budget to maximize savings.

As your advisor, we help you purchase the best coverage at the most economical cost from the total marketplace. This unique advice helps assure the success of our clients in today’s challenging economy.

We use a variety of pricing models to pinpoint and assure the best solutions, deductible ranges and cost for various populations.

We help design specific coverage tailored to a client’s unique needs. This ranges from:

Specific and Tiered Per Diems
All Costs and Services – Per Diem and No ADM Programs
Funding Vehicles – conservative to aggressive programs
Specialty Rx Coverage + First Dollar Rx
Drop Down Deductible

HMO/Health Plan Reinsurance – We provide commercial, Medicaid and Medicare HMOs with risk solutions to help mitigate catastrophic exposure and offer tools and services to assist clients address a wide range of financial risk strategies.

We believe that Managed Care = Managed Cost = Managed Profits/Savings. We work closely with clients to: see colon to insert??

We act as a sentinel for the client to mitigate and reduce risk by for the client. High-Cost Trigger Identifiers are used producing early intervention in cases where excessive medical expenses could result. Successful cost management can be implemented to help reduce the financial impact for the plan. By working collaboratively with our clients, we use the reinsurer’s medical management/cost containment programs to protect their bottom line from the financial impact of catastrophic high-cost events.

We connect our clients’ financial and clinical experts, i.e., CFOs, risk managers, nurse case managers, etc. to evaluate each case and provide suggestions and solutions that can help optimize financial outcomes. Part of our advice is to help select the best Transplant facility on Transplants and other “high-cost” cases.

3. Provider Excess Liability Insurance (Capitation Stop-Loss)

Provider Excess Loss Insurance (PEL) – This coverage, also referred to as capitation stop-loss, is available from reinsurers to reduce the provider’s financial exposure. We actuarially analyze risk exposures, coverage needs, claims experience and financial risk to assist at-risk provider firms in helping to minimize their financial exposure from catastrophic high-cost claims and cash-flow. PEL coverage protects health providers from a portion of the financial risk they assume in managed care contracts with insurers/HMOs. It helps reduce the provider’s financial exposure by limiting financial responsibility to a specific dollar amount per patient, per year for the services covered in a capitation risk contract.

As your advisor, we help you purchase the best coverage at the most economical cost from the total marketplace. This unique advice helps ensure the success of our clients in today’s challenging economy.

Provider entities (physicians and hospitals) accepting capitation, shared risk, contracted per diems and defined budgets “risk contracts” can benefit from these at-risk models using reinsurance to gain and protect profits and budget.

We believe it is a New Day + New Dollars = New Profits for Providers. NRA was at the genesis of the provider reinsurance industry in 1991 as former reinsurers.

Our experience has benefited our clients by allowing them to capitalize on our expertise and negotiating power as follows:

Inventive Financial Funding Solutions to minimize reinsurance cost
Deductible Stratification for most cost-efficient price point and potential 50% savings at reduced deductible on identical insurance protection
Advanced Risk Protection at the Same Reinsurance Cost
Custom Deductibles & Coinsurance
Tailored Disease & Procedure Only Insurance, i.e., bundled payments, ortho procedures, chronic kidney disease program, etc.

Provider reinsurance is one of the most complex insurance products on the market today and can be costly when bought from the HMO. When purchasing PEL, a provider must carefully review the proposed coverage, risk transferred from the HMO and the net cost of the various options. While the contract period, deductible and coinsurance levels are usually straightforward, the reimbursement basis might vary from one reinsurer to the next. For example, with physician risk using the Resource Based Relative Value Scale (RBRVS), some reinsurers will specify a conversion factor, whereas others will state “geographically adjusted” for a specific area. Similarly, with hospital risk, there may be differences in the per diem schedules that are specified.

MA Capitation Reinsurance

Savings of 10% to 30%
Broader Coverage Grants
Creative Risk Solutions Using Shared-Savings Funding Models
Increases Cash-Flow
Mini-Gap Tranche Program – Allows small firms to compete for significant profits
Actuarial Assessment for Best Net Cost & Deductible Price Points
Actuarial Risk Stratification Analysis – Drives More Profits
RX – AI Analytics for 20%-30% Lower Costs and Better Management
Captive Options – Better Control, Risk Management & Profits

While HMOs typically offer capitation reinsurance, there are clear benefits to securing reinsurance coverage from your own reinsurer:

Uniform coverage that combines all the provider’s capitation contracts in one reinsurance policy. This means only one policy effective date for claims tracking and submission purposes, one deductible level and one excess policy to review annually.

One policy deductible even if a member switches mid-year between HMOs.

One company to which claims are submitted and to which questions and service needs are directed.
Clearly defined excess loss insurance policy outlining the contract period, deductible and coinsurance levels, reimbursement basis, maximum reimbursement and limitations and exclusions.

The ability to “roll” other capitation contracts into the initial excess policy from new or existing HMO contracts being converted to capitation contracts.
Cost economies – When excess loss coverage is purchased from the HMO, the deductible level is set based on the number of members covered under that contract. Maintaining separate deductibles for each contract is not only cumbersome for reporting and claims submission but usually results in keeping deductibles at artificially low levels with more costly premiums.

Risk Consolidation – Increased Savings arise by establishing the deductible level based on the aggregate number of members from all capitation contracts increases the mass buying power and quantity discounts to the provider. Thus, the provider can accept a higher deductible for all members which may significantly reduce premium costs.

Additionally, out-of-area emergency is one of the most difficult exposures for providers to manage, and consequently one of the largest areas of risk for a reinsurer and is always an important concern.

4. Employer Stop Loss for Self-Insured Group Health Benefits

Employer stop-loss reinsurance (also known as “excess insurance”) is an insurance instrument used by self-funded health plans to financially protect the employer from budget buster claims due to high-cost catastrophic medical expenses that exceed the plan’s actuarial predictions. The same stop-loss protection can be employed by a partially self-funded health plan, sometimes referred to as “level funded,” where the plan is under management of a third-party insurer instead of the entity whose employees are being insured.

In both scenarios, the stop-loss reinsurance allows a health plan/employer to reduce the premiums it charges enrollees by limiting the maximum expense of medical claims within a given year. This predetermined limit where a stop-loss policy begins to pay for an employer’s/health plan’s excess medical claims is known as the “attachment point.” Additionally, the health plan’s premiums incorporate the cost of the stop-loss insurance rather than full financial expense against which it protects.

Stop-loss further reduces financial expense of keeping adequate operational funds in reserve. Since a health plan’s premiums are normally collected monthly, a health plan’s cash flow can be compromised if a high medical claim occurs earlier in the year. However, a health plan can use “individual stop loss” coverage alongside its aggregate stop loss covering the risk pool. Individual stop loss provides funds for a high expense individual medical claim even if the health plan’s total aggregate attachment point has not been reached. Reinsurance/stop loss, if designed correctly, can provide advance claims payments to expedite and facilitate budget restoration.

A self-funded employer’s balance sheet for group health benefits is protected against infrequent but catastrophic claims so the profits remain stable without negative cash drain against corporate assets. Insurance is bought for both specific and aggregate deductibles using a variety of funding methods that matches risk to corporate budget to maximize savings.

As your advisor, we help you purchase the best coverage at the most economical cost from the total marketplace. This unique advice helps assure our clients’ success in today’s challenging economy.

Program Design & Considerations on All Costs, All Services Basis:

Specific & Aggregate Insurance
Level Funded
Risk Sharing Options
100% or 90% Coinsurance
National Program for Physician-Led Groups @ Rate Discounts
Flexible Deductibles
Dividends Return

Manage Your Risks: Our unique risk model allows employers, especially physician-led firms, to halt the continuous premium cost year-upon-year and start reducing the overall cost of funding group health benefits. By using “best-of-the- best doctors” allows employers to manage the risk for more savings. Many employers receive the following benefits …

Reinsurance premium savings between 30% to 50% are normal for clients
Specific claim and aggregate claims basis
Spousal conveyance to reduce your deductible by 50% at the existing premium cost today
Advance claims funding to increase cash-flow and lower out-of-pocket costs
Longer claims paid and filed terms at no cost
Potential dividend with favorable losses
Claims carryover of 31 days upon renewal
Cap Medicare allowable limits for additional savings
Referenced Based Pricing
Wrap Networks including National Transplant Networks
Real-time claims access

5. ACO Reinsurance

National Risk Advisors has developed a new Reinsurance Program in response to the final regulations published recently by CMS for the Medicare/Medicaid ACOs At-Risk Programs. The program is a response to physicians’ need to eliminate downside risk under the new ACO Regs for Reach, Enhanced and MSSP programs and allows them to capitalize on the increased profits potential.

“We recognize the unique requirements of firms that want to participate in the ACO Shared Savings Program and their need to moderate their downside risk in an affordable fashion,” notes Terry Chesser, National Risk Advisors ‘ Principal. “We have been tracking this issue from the draft regulations, and our team has been working on the development of this new program for a number of months.”

The ACO Reinsurance Program recognizes the delayed cash flow compared to traditional health care financing mechanisms, as well as other unique aspects of the CMS At-Risk Programs. It is designed to protect an ACO’s capital as they take risk on Medicare and/or Medicaid members.

Eliminates pressure from the downside risk and the cash flow requirements of the ACO
Significant Additional Profits of New CMS Models
Rates Competitive and Consistent with Integrated Clinical Model of ACO
Risk Model Tailored to CMS Regs, i.e., payment schedule to Docs, true up provision, funding trigger points, etc.
$20,000,000 Capacity Limit
Minimum Coinsurance Participation of 10%
Due Diligence required for those ACOs in order to Qualify for participation in the Program
Placement by Domestic Reinsurers

”National Risk Advisors has studied the environment closely and believe that we have an ideal program for those ACOs who have the motivation to improve quality and efficiency, yet may not have the deepest balance sheets and would otherwise not be able to take advantage of CMS’ profit sharing rewards,” notes Tommy Axford, Director of Actuarial Services of NRA.

6. Risk Sharing/Funding Options

Securing true aggregate coverage in the market today is challenging. However, Inner Aggregate or Aggregating Specific Deductible policies can be widely available. In a Hospital Aggregating Specific policy, coverage is provided for hospital inpatient charges on a specific (per person, per year) basis. This program (double deductible, single trigger pay-out) reimburses the client after the specific recoveries exceed the Aggregating Specific deductibles as totaled and stated in the policy. The first claims are internally funded, and paid immediately by the client to itself. Because no loads are placed on internal funds, premium costs are significantly discounted in this risk sharing model.

Other risk sharing options include risk corridors on a percentage/donut hole basis, retro and swing rate programs. We can measure the benefit of various risk options actuarially.

7. Captives

The uses of a captive extend to a variety of risk types: PEOs, HMOs, Physicians, CINs, Hospitals, Group Benefits, TPAs, etc.

We arrange Captive Insurance beginning with actuarial risk assessment, captive formation and management. We utilize a team of professionals in the area of actuarial, accounting, legal and captive management to assure the best combination of risk vs. capital in establishing a captive. Captives can take several forms ranging from:

Sole Ownership
Multiple Ownership – Association Captives, Group Captives
Cell Captives – Rent-A-Captive

Services Available:

Captive Formation Analysis
Actuarial Feasibility Study
Captive Management
Selection of Domicile
Reinsurance Placement and Structure
Fronting Carrier

Benefits of Owning a Captive

Creates Capital – As you fund the captive, since it is not remitted to an insurance company, it remains an asset in your firm’s name. Using a traditional malpractice approach means giving the insurance company premium but at the end of the year the money is gone and you still may have a rate increase with no losses and a significant increase if you have a loss event.
Reduces Cost – It can reduce funding in later years while potentially lowering your cost for any excess insurance since you can raise the deductible over time with no losses and/or favorable losses.

8. Directors and Officers Liability Insurance (D&O)

D&O insurance liability policies provide insurance for negligent acts, omissions or misleading statements committed by directors and officers of a company that result in lawsuits being filed against the company. D&O coverage can be purchased to reimburse the company when it indemnifies directors or officers, to specifically cover directors or officers when the company doesn’t indemnify them or can provide entity coverage to cover claims made specifically against the company.

Suits can arise from employees, providers, customers, vendors, creditors, competitors as well as government agencies. While the entity/firm is at financial risk when a D&O claim is made, the board members’ personal assets are also at risk. D&O insurance can protect board members and officers against personal liability. Key D&O exposure includes anticompetitive acts, shareholder liability and mismanagement.

Coverage should be comprehensive with minimum exclusions to be truly effective in protecting HMOs, MSOs, IPAs, providers, etc. The directors’ actions, business practices and decisions are constantly under review from regulators and the public and should be protected from serious financial loss arising from suits.

National Risk Advisors can work with you to implement a sound risk management program to identify potential gaps in existing insurance coverage and make recommendations for their correction. We are a specialized team of managed care liability experts and offer managed care firms the broadest coverage to protect your liability exposure, including Directors and Officers liability (D&O).

Your balance sheet is protected against suits brought against the corporation arising from Managed Care by the acts of the Directors and Officers such as:

Failure to devote proper time and attention to the business
Financial operations of clinical services
Hiring and managing the staff
Vicarious Medical Malpractice Liability
Educating the nursing staff, physicians and other departments regarding operational issues
Coverage for your organization (entity) even if you have employed providers
Outside Board Exposure
Spousal Coverage
Suits from Shareholders
Anti-Trust Coverage for suits brought by both providers and competitors
Defense Expenses
Prior Acts

Program Features:

Crime insurance, cyber liability, directors & officers liability, employment practices liability, fiduciary liability, kidnap & ransom
Third party, antitrust and regulatory coverage options
EMTALA, HIPAA, excess benefit transaction and internal revenue code (IRC) coverage
Broad definition of insured persons

Special Note: Other Insurance Coverages to consider ….

- Employment Practice Liability (wrongful dismissal, sexual harassment, etc.) or it can be insured under the D&O.
- Employment Benefits Liability – not communicating the group health, disability, life, etc. correctly to employees. This can be included under the General Liability policy.

9. Managed Care Errors & Omissions Liability Insurance (E&O)

Managed Care E&O: Errors and Omissions insurance is coverage protecting against wrongful recommendations, design solutions, or management input. Coverage protects when something is done that should not have occurred (error) or when failing to do something that should have been done (omission).

It is also referred to as Professional Liability or Malpractice Insurance. This is one of the most important managed care exposures that is often bought by HMOs but MSOs/IPAs may not be aware of the importance of this coverage. Claims arise from normal operations of delivering service to the entity’s members. E&O liability coverage protects firms from allegations of management negligence, including the exposure area of vicarious liability, credentialing, peer review, provider selections, utilization review and claims processing. It is important that all managed care organizations, from small to large, that provide credentialing or utilization review for managed care plans should purchase E&O coverage.

Insured Activities – Provider Selection, Utilization Review, Claim Services, establishing provider networks, sales/marketing or enrollment of HC plans, wellness programs, development of clinical guidelines, etc. plus a “catch all” for services or activities performed in the administration or management of healthcare or workers’ compensation plans. Our ability to apply the facts and narrow the issues has benefited clients in controlling their cost and receiving valuable insurance protection. Thus, clients have benefited and appreciate our ability to broaden coverage without any extra premium such as:

Credentialing, Utilization Review, Peer Review and Health Care Management

Vicarious Liability – liability imposed upon an insured under theories of agency, ostensible agency, apparent agency or respondent superior as a result of the performance or non-performance of medical services by a contracted health care provider.

Coverage for claims staff in the processing of claims, case management, provider credentialing, medical director, enrollment and processing, and marketing/contracting

Employment Practices Liability (ERISA)

Failure, Denial or Delay in Treatment

TPA claims risk

Medical Directorship Liability

Medical Malpractice complaints or suits arising from Managed Care

Telephone Triage Services and Call Centers

UR, Claims Administration, Case Management, Advertising, Marketing & Selling Activities

10. Capital Surplus Relief

As one of the leading firms in surplus relief, we have provided capital/reserve solutions for our HMO’s risk and capital-motivated reinsurance needs. Our team of reinsurers is adept at the measurement and quantification of reinsurance risks and can assist in determining the level of economic capital necessary for HMOs. This expertise enables us to tailor financial solutions that add value in reducing your reserves/IBNR and capital/surplus requirements to the State Department of Insurance.

HMOs often have a need for additional capital to satisfy statutory risk-based capital requirements. This can be caused by growth, acquisition or profit and loss experience.

HMOs have used our programs to support new business growth, manage reserve strain, or free-up surplus for acquisitions. Key attractions to these programs are the low transaction costs and flexibility in structure, size and duration.

Programs go by many names such as:

Financial Reinsurance
Structured Reinsurance
Capital Surplus Relief
Risk Based Capital Relief Reinsurance
Transactional Reinsurance
Risk Based Capital Surplus Relief
Quote Share Reinsurance
Finite Reinsurance

11. Financial and Credit Solutions

Capital Raising

We provide advice to insurance related entities and management buy-outs that are looking to access new capital. We can provide access to a wide range of domestic and international capital sources, including:

Private equity and venture capital;
Trade investors and specialist insurance investors;
Capital from reinsurance providers: quota share and reinsurance gearing arrangements;
Private investors and international sources; and
Specialist debt instruments and debt finance (short and long-term)

Aggregate Capital Reinsurance

The Aggregate Capital program reimburses the client after the total capitation budget, risk corridor, and line of credit have been exceeded (single trigger pay out). This state of the art program combines capital access with aggregate reinsurance providing superior coverage at a reasonable cost.

Capital credit and/or Provider Operating Deficit Aggregate Reinsurance

The Provider Operating Deficit Protection program (dual trigger pay out) consists of a reinsurer-backed $100,000-$200,000 specific stop loss combined with an Aggregate coverage.

The coverage pays the lessor of the Specific recovery, or brings the client back to their target Medical Loss Ratio (MLR). The policy pays out on a Specific basis, until the targeted Medical Loss Ratio is restored to the 85th-100th percentile. This policy offers about 60% savings over a stand alone Specific coverage.

Applies to: Total Targeted Capitation Budget + Capital Limit + MLR Deficit

Community Health Plans Capital Aggregate Program

This is an aggregate reinsurance program which provides two major features:

Aggregate reinsurance attaching at 100% (not 125%, as is typical).
Capital placed on the client’s Balance Sheet of $1-$2 million. The capital is priced at 5% of placement.

This product offers a very competitive alternative to the venture capital markets which typically requires equity, 15%-20%+ equity appreciation, pay out in less than three years, and 10% interest.

12. Medical Malpractice

Coverage Points

Coverage protects physicians and hospitals against suits from 3rd parties for acts creating an injury or accident to the patient. We represent some of the largest insurance companies underwriting this business and can arrange deductibles or risk funding programs to match your risk appetite to your risk exposure.

Choosing malpractice insurance can be confusing, time-consuming and costly, especially when you do not do it on a daily basis. Purchasing the right coverage at the right price is critical, but how can you be sure the coverage you select is right for you?

We work with and know the major insurance companies to extract the best coverage and cost. Thus, we can match your risk exposure to the best carriers.

Your Needs

We review and evaluate your hospital or practice risk to determine the best carrier based on your geographic region, medical specialty, claims experience, practice size for coverage options and rates that correspond to your needs. We put physicians in a position to make an informed decision for your long run benefit. We meet with you to review the best options and make recommendations so you can decide which insurance coverage and rate best meets your needs.

Solutions

National Risk Advisors is a national broker with vast experience and resources. We are committed to helping hospitals and physicians find affordable medical malpractice insurance through quality carriers.

We bring creative coverage and funding options to you in selecting the best and most qualified malpractice carriers matched to your risk and practice needs.

You will be rewarded with affordable coverage for your practice and the security of working with quality carriers and a broker committed to long-term relationships.

13. Cyber Liability

Protects the firm for cost to restore as well as damage to equipment and can include coverage for ransom (ransomware liability).

CYBER RISK

The Internet is increasingly becoming a critical delivery channel for health information, referrals, scheduling, billing, research, and prescription fulfillment. Automating traditional workflows can improve care management and operational efficiency. But automation also brings new responsibilities and unprecedented risks. The accessibility of the Internet increases a healthcare company’s vulnerability to the theft, alteration or accidental display of confidential patient information. Such exposures can affect an organization’s earnings, reputation and operations.

By enacting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress raised the importance of privacy and security to the national level. HIPAA regulates the electronic possession, transmittal and access to patient health data and provides patients with much more control over the distribution of their information. Laws like HIPAA significantly increase a healthcare provider’s exposure to litigation. Since traditional insurance policies do not provide sufficient coverage, network liability and web content privacy insurance are necessary components of a comprehensive risk management program.

MAJOR RISKS ARISE OUT OF THE INTERNET AND COMPUTER NETWORKS

Damage, Theft, or Disclosure of Patient Electronic Medical and Financial Information. Today’s criminal can hack into a database and steal large quantities of confidential data in seconds. Disgruntled employees can also use a company’s computer network to destroy information or steal it to sell for a profit. Protecting a patient’s privacy is paramount – but this risk cannot be managed by firewall technology alone.

Attacks and Malicious Code. Any company connected to the internet is susceptible to viruses which can result in legal liabilities as well as damage to, or destruction of, patient and other valuable information.

Intellectual Property and Content Infringement. The Internet creates new exposures for content and advertising litigation. Healthcare companies can be liable for misleading or inaccurate medical information.

Unintentional Disclosure of Private Patient Information. Considering the volume and complexity of information handled by today’s healthcare providers, there exists a significant risk of unintentional disclosure. Disclosure on a healthcare provider’s website could lead to HIPAA violations and the breach of privacy policies.

CYBER NSURANCE PROTECTION: Cyber Insurance is designed to fill critical gaps in your operational needs for the on-line activities of healthcare organizations. You can tailor the extent of coverage you need as well as select different limit and retention options. NRA can design and construct insurance protection to address your coverage needs:

Network security breaches
Information theft
User content
Privacy violations
Cyber terrorism
Cyber extortion
Network security business interruption
Cyber-related public relations costs

14. Surety Bonds

Surety Bond Overview

Surety bonds are a financial credit instrument and substitute for LOCs and cash. CMS requires ACOs to have the ability to repay all losses for which it may be liable.

ACOs can meet its obligation to comply with CMS’ repayment mechanism requirement by posting a Surety Bond which is one of the simplest and least costly methods. The three parties to the surety financial agreement include the principal (ACO), oblige (CMS) and the surety (bonding firm issuing the bond). The Surety agrees to become contractually liable for the ACO’s repayment penalty but will seek repayment from the ACO if they incur a loss.

Surety Bonds allow the ACO to meet its financial obligations to CMS for repayment if their performance and guarantees fall short. Bonding firms offer the surety as a service to relieve the financial strain of posting cash or other financial guarantees. Thus, bond firms always underwrite to a zero loss ratio since it is a service, and they never expect to have a loss. In some instances, depending on the ACO’s financials, the surety firm may want collateral which could be either a percent of the bond limit or the full amount of the bond.

Surety Bond Advantages for ACOs

CMS compliant as repayment mechanism
Cost efficient vs. bank Letter of Credit (LOC)
Frees ACO’s capital for investments in operations and acquisitions
Eliminates countermanding balances of an LOC
Collateralization minimal or none
LOC immediate payment eliminated using bond delayed payment process

15. Fidelity/Crime Insurance

Fidelity/Crime Insurance Description and Overview

Commercial Crime Insurance: This insurance offers protection from employee theft or fraud that impacts a client. It is also referred to as fidelity insurance, financially protects your business from criminal acts committed by employees against customers or clients. If one of your employees (or anyone else working on your behalf) steals from a customer or client, crime insurance provides them with reimbursement for the amount that was stolen.

Fidelity Bond: This type of coverage is sometimes referred to as a first-party bond. Commercial crime also covers employee theft against the insured, if the policy includes first-party coverage. Third-party coverage can protect a client against losses resulting from theft by an employee. This type of coverage typically comes in the form of a fidelity bond. Essentially, fidelity bonds serve as a type of crime insurance coverage.

The criminal acts typically covered by a commercial crime policy include:

Theft of money or property, including embezzlements
Fraud, including computer fraud and funds transfer fraud
Employees’ crimes against your business or clients

Transfer-of-funds fraud or forgery
Third-party theft or robbery of money or securities on- or off-premises

With business crime insurance, the policyholders must specify whether they want coverage to be on a discovery or loss sustained basis. Discovery coverage covers crimes identified and reported within the policy term, regardless of when they happened. Loss sustained coverage only covers crimes that both occur and are discovered during the policy term or within a year after it expires, assuming an extended discovery period applies.

Cost: Commercial crime costs can vary depending on the type of coverage. Factors that affect costs include:

Amount of coverage or size of the bond
Deductible, if any
Personal and financial information handled
Number of employees with access to sensitive information
Your credit rating

Limitations/Exclusions – What Isn’t Covered: In general, business fidelity/crime insurance doesn’t provide coverage for banks or other financial institutions. It also doesn’t cover crimes perpetrated by your business partners or other company executives, even if an employee is also involved. If you knowingly hire someone with a criminal record and that person steals from you, those losses aren’t covered under your business crime insurance. Your policy also won’t cover losses from employees who commit multiple offenses – in other words, offenses that take place after the employee commits an initial one. Although business crime insurance covers some digital crimes, such as if a hacker steals money from you through fraudulent means, the policy won’t protect you from a data breach where the hackers steal sensitive client information. You’ll need cyber liability insurance to cover cyber crimes.

Other things not covered under business crime insurance include

Employees with criminal records known to employers – If you hire an employee with a known criminal record and they commit fraud or theft, commercial crime insurance will not be applicable.
Crimes by business owners or senior management – A commercial crime insurance policy insures your business only against employee theft or fraud. This does not include business owners or senior management.
Indirect financial losses – Indirect financial losses, such as business interruption, loss of income, or legal expenses, are not covered under commercial crime insurance. For protection against indirect financial losses, you should get business interruption coverage.
Data breaches – If a data breach occurs at your business by an employee, commercial crime insurance would not provide coverage for related expenses, such as customer notifications. You should get data breach insurance, also known as cyber insurance, for this protection.
Unverifiable thefts

Liability and other legal expenses to third parties
Theft of intellectual property, trade secrets, or client lists
Theft of business personal property and equipment other than money and securities
Damage to buildings and equipment, unless resulting from covered robberies

Benefits of Business Fidelity/Crime Insurance: Almost any firm with employees or volunteers could use business crime insurance. The coverage is especially beneficial for businesses where many employees are part-time or where there is a high turnover rate. Business fidelity/crime insurance is also essential for businesses that have a lot of cash transactions (other than credit unions and banks), rely on electronic transfers, maintain an inventory of products, or use expensive office equipment.

16. Rx Consulting & Programs

Our mission is to remove the PBM mystery out of how an HMO or Provider’s medications are suggested, dispensed and ultimately paid for by our clients. We identify the revenue streams, negotiate away the misaligned incentives, and monitor the claims to ensure that bad behavior is not present. If it is present, we present data based reports to clients and then assist in the correction of the behavior to help our clients recoup the monies that they are due. Our goal is to assist in the establishment of a long-term relationship between our client and its PBM partner. A new vendor should only be considered when all efforts to create a win-win relationship have failed. We currently deal with a group of clients representing over 7.5 million lives.

We are committed to ensuring our clients are buying their medications as smartly as possible. Our team is made up of high-level managers from the major Prescription Benefit Management (PBM) companies.

Benefits of National Risk Advisors’ Assistance

You get the best cost and program since you now have the same knowledge as your PBM

Significant Savings – from 30% to 60%
Savings starting as early as 60 days
PBM Monitoring and Oversight
1st Dollar RX Capitation
On-Site Medications for Physicians and ACOs, MSOs, IPAs
Metabolic RX Program for Increased Absorption Efficacy

Reinsurance Thoughts and Strategies

As firms expand and grow you have risk on your books. We remove this risk using advanced risk solutions and financial reinsurance. In thinking and working with you we want you to receive a “pele” of risk solutions. Our role is to provide the proper advice, precise risk strategies/solutions, and be your advocate for better coverage and better cost. Thus, when risk obstacles arise, we can respond with the most appropriate solution to build a firewall of risk protection. We do so, as former Reinsurers, since we understand how to identify, interpret and implement the best risk solution for the risk problem based on our decades of experience and creativity.

We use risk logic, developed from serving over 4 million lives nationally, to solve complex risk problems to help clients mitigate risk and achieve greater success. We are very good at diagnosing risk problems and then using our expertise and creative thinking to advance risk strategies/solutions for clients in solving their risk needs and problem.

Reminders From National Risk Advisors

Please think of National Risk Advisors as your one-stop shop in providing options from major reinsurers for all your Managed Care Reinsurance needs. As such, we become your in-house risk management department handling all aspects of Reinsurance to take the administrative burden off your firm. We concentrate on understanding our client’s risk thoroughly to develop and design an optimal coverage solution that is appropriately priced. Working with the total marketplace, at the C-Suite level, allows clients to obtain more than one solution and not become locked in to only one solution that may not be in the client’s best interest.

This perspective and commitment to serving clients first and foremost, allows us to provide targeted and custom risk solutions vs. an off-the-shelf product where “one size fits all.” Thus, we work diligently to protect our clients from the potential harmful financial losses arising from unexpected, unanticipated, expensive, and unaffordable healthcare costs. As a privately held firm we answer only to you in making you money or saving you money and effectively delivering the best Price/Value possible.