Medical Loss Ratio Requirements Under the Patient
Protection and Affordable Care Act (ACA)
The 2010 Patient
Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) requires
certain health
insurers to provide rebates to their customers for each year that the insurers
do not meet a set
financial target called a medical loss ratio (MLR). At its most basic, a MLR
measures
the share of a
health care premium dollar spent on medical benefits, as opposed to company
expenses such as
overhead or profits. For example, if total premiums collected are $100,000, and
$85,000 is spent
on medical care, the MLR would be 85%. The ACA sets the minimum required
MLR at 80% for the
individual and small group markets and at 85% for the large group market.
In general, the
higher the MLR, the more value a policyholder receives for his or her premium
payment. Congress
imposed the MLR in an effort to provide “greater transparency and accountability
around the expenditures made by health insurers and to help bring down the cost
of health care.” Insurers that fail to meet these minimum standards must
provide rebates to
policyholders.
Even if a
beneficiary had no medical claims during a given year, he or she would not
receive a
rebate if the
broader plan met the MLR requirements. In addition, many Americans were
enrolled in health plans that were not covered by the ACA MLR provisions in
2011. The ACA MLR provisions cover only fully funded health plans, which are
plans where insurance companies assume the full risk for medical expenses
incurred. The requirements do not extend to self-funded plans, which are health
care plans offered by businesses in which the employer assumes the risk for,
and pays for, medical care. Non-profit insurers and some Medicare Advantage
plans were not covered by the ACA MLR standards in 2012, though the MLR
provisions will be phased in during 2013 and 2014, respectively. In addition,
some states won special exceptions for individual insurance policies, based on
a HHS determination that meeting the MLR requirement would harm a state’s
insurance market.
We are proud to introduce MCAR REPORTS a
complete set of management reports for IPAs, MSOs and PCP Practices that have
Risk Agreements with HMOs Plans. The MCAR Reports give you complete awareness
over what is happening with every HMO Plan that your organization participates
in risk operations.
MCAR - MANAGED CARE REPORTS is an online
service available created from data files downloaded from HMOs servers. Within
24 to 48 hours our team produces all reports needed to manage your risk
business. MCAR Reports are viewed from our secured HIPPA compliant servers
however most reports are downloadable in EXCEL format files.
MCAR Reports services can range from only
generating reports to having our management team assisting clients in managing
the risk operations.
Clients can select MCAR Report services “A LA
CARTE” choosing monthly reports needed and/or consulting services they prefer.
Here are some of the options available:
·
Control over HEDIS requirements,
alerting what measures apply to each member of the HMO panel and most importing
identifying what measures are pending per member in the reporting period.
·
Summary analysis of funding and
expenses including expected distributions, in minutes you know what is going on
with your risk operation.
·
A PCP Analysis that shows
performance for each PCP in the network from funding, expenditures to net
amount after medical expenses. A simple and easy report that enables you to
identify and compare all PCP’s performance.
·
MCAR produces a detailed analysis of
charges payments and adjustments from Institutional, Professional and Pharmacy
claims.
·
A key report - Summary Report
showing what each member is costing the panel, a brief breakdown of medical
expenses also showing when was the last time the patient came to the office, if
ever.
·
A detailed analysis showing all
activities for every member - HEDIS measure status, diagnosis codes with MRA
evaluation plus each line item of expenses – YOU CAN VIEW THE PRECISE COST OF
EACH MEMBER OF THE PANEL.
·
STOP LOSS verification.
·
MCAR Reports claims module – “The
ADJUDICATOR” scrubs your professional, institutional and pharmacy claims and
also prepares a contestation report requesting adjustments from the Plan.
·
The ADJUDICATOR module employs the
most sophisticated scrubbing techniques following CMS and AMA guidelines in
processing professional and pharmacy claims.
For more details please contact
305-227-2383 or 1-877-938-9311
Ask for a Free Trial or Webinar
Please visit : www.accuchecker.com
Paul G. Silverio-Benet
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