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Provider Excess Loss insurance is designed to protect at-risk health care providers from the financial impact and volatility of catastrophic health care claims.  As the healthcare market continues to evolve into a “value over volume” environment, providers will be asked to take on increased financial risk for providing care to their patients.

Provider Excess Loss

Under a capitation contract, an HMO or managed care organization pays a flat, prearranged payment in advance per month to the health care provider to provide care for their capitated members. The set dollar amount per month is paid to the healthcare provider regardless of how many services the patient needs. 

The provider excess loss insurance coverage is designed to financially protect the provider from unforeseen high dollar claim costs that exceed a selected retention level.  Policies are usually written on an individual member, per-year basis, which is often called “specific,” though some policies also include aggregate provisions, based on the claims experience of an entire group of patients.  Coverage can be designed with a variety options to meet the organization’s needs and risk tolerance.

Eligible services can include any combination of inpatient hospital, outpatient hospital, sub-acute, professional, ancillary, pharmaceutical, and organ transplant services.

* Please note that if the PACE entity is licensed to accept global risk for the health care of their members (i.e. Knox-Keene license), then the coverage will be written as an HMO Reinsurance policy.

A few key points that make Pinnacle a unique broker are as follows:

  • Claim Auditing Services. We can audit 1 to 3 years of claims data for billing and payment errors, duplicates, and trends in the data.

  • Claim Filing Services. Clients have the ability to send Pinnacle a “data dump” of all of their paid claims for the policy year and Pinnacle will prepare the proper submission to the carrier.

  • Pre-Carrier Claims Adjudication

  • Underwriting Expertise

  • Deductible Analysis

  • Pended Claim Tracking

  • Quarterly Reports and Division of Financial Responsibility Matrix Review

  • Full Transparency

  • Strong Relationships with Most Major A+ Rated Stop-Loss Carriers

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