PLACEMENT OF THE HEALTH CARE &
LIFE INSURANCE COMPONENTS OF A
FLEXIBLE BENEFITS PLAN
The objective of this project was the selection of and negotiation with health care and life insurance providers for flexible benefits of one of the largest pharmaceutical firms operating in the Philippines.
Our firm provided advice on the inclusion and deletion of benefit components and the level of support on the cost of the plan. The local health insurers and pre-need firms were not familiar with the underwriting and pricing of flexible benefits plans having had no experience in this regard. The scope of work included the selection of providers based on certain criteria, one of which was access to technical expertise in flexible benefit plans. The scope of the project also included benefit review, utilization review and a review of demographics. Negotiation with the providers involved creation of underwriting controls to minimize anti-selection. Our team also provided assistance in pricing negotiation. The project scope also included plan communication and the administration of enrollment into the health care plan.
MANAGE CHANGES IN THE HEALTH
CARE BENEFIT OF A BANK
The objective of this project was to transition the health care benefit of the largest foreign commercial bank in the country, from a traditional plan to a comprehensive Managed Care plan, without increasing the cost of the benefit. The firm was also interested in expanding the benefit without increasing its cost. As the bank was unionized, the challenge was to implement cost control methodologies without a perceived diminution in benefits.
The scope of the project involved benefit review --- objectives and design; utilization review; proposed changes in plan design; calculation of plan cost including review of historical, current and projected demographics; provider selection including review of criteria in selecting a provider, bidding, and negotiation; and plan communication.
After the launch of the plan, monthly meetings were held with both the provider and the user to thresh out issues with the network, quarterly to review plan utilization and at year-end to discuss the employee satisfaction survey.
MANAGE CHANGES IN THE HEALTH
CARE
BENEFIT OF A PHARMACEUTICAL FIRM
The objective of this project was to transition the health care benefit of this multi-national firm after a worldwide merger with another firm.
The challenge was to come up with a single plan design across the firm when half of the merged population was enjoying far more superior benefits than the rest. Furthermore, the firm had a mandate from their head office to maintain the same budget for the year. As the firm was unionized, the resulting plan design should not result in perceived diminution in benefits. A further challenge was that there was no cap on the age of dependents, so that there were quite a number over 70 years old.
The scope of the project involved benefit review --- objectives and design; utilization review; proposed changes in plan design; calculation of plan cost including review of historical, current and projected demographics. Provider selection and negotiation as well as plan communication were crucial to the project.
After the launch of the plan, regular meetings were held with both the provider and the firm to thresh out issues on plan administration and utilization.
REVIEW OF THE HEALTH CARE BENEFIT
OF A LARGE SEMI-CONDUCTOR FIRM
The objective of the project was to review both the design and the method of delivery of the health care benefit of a large semi-conductor firm.
The scope of the project included a review of the benefit objectives of the firm. Since the firm did not have a written philosophy, the project started with the development of one, specifically for health care. The firm’s views on benefit adequacy, competitiveness, plan stratification, plan cost and plan eligibility were reviewed and documented. The administration of the current plan was also reviewed including in-plant clinic staffing and wellness programs in place. After a final plan design was prepared, the cost of the plan was estimated. This was followed by provider selection including review of criteria in selecting a provider, bidding, and negotiation.
THIRD PARTY ADMINISTRATION OF A
SELF-INSURED HEALTH CARE PLAN
The objective of this project was to provide assistance in the management of the self-insured medical plan of a software-consulting firm.
The undertaking started with the review of the benefits in place. The first phase of the project involved the preparation and documentation of a plan design and plan administration guidelines. An estimate of the plan cost and funding levels followed. A Claims Data base and monitoring software was developed. Forms were designed including Claim Forms and Claims Calculation Sheets. Claims utilization reports were prepared.
Day-to-day administration involved review of receipts versus prescriptions. Compensability of the claim was determined by reviewing the diagnosis indicated on the Medical Certificate versus the plan rules. Based on these, amounts to be reimbursed were determined and paid out. Queries from claimants were addressed.
ANALYSIS OF EMPLOYEE LOAN
PROGRAMS OF A FIRM
The objectives of this project were to analyze the desirability of providing loans from the employee’s point of view, to analyze the relative cost to the employer of providing these loan programs, to provide a general analysis of the existing loan programs and to propose possible alternatives to the current programs. The firm was also interested in controlling employee turnover and minimizing its financial exposure.
The following items were reviewed in the course of the project: Loan Utilization, Security and Risk, Employee Demographics, Market Practice, Commercial Loan Markets and the firm’s Current Loan Programs
A Financial Analysis was prepared and the cost to both the employer and employees were measured. Available alternatives were presented for the benefit design, financing and administration.
ACTUARIAL STUDY ON THE ENHANCEMENTS
IN THE NATIONAL HEALTH INSURANCE PROGRAM
The objective of this project was to develop financial projections in order to assist in the assessment of the financial soundness of the NHIP given its current status and the strategic directions and operational plans set by the Philippine Health Insurance Corporation ("PHIC" or "Philhealth"). In particular, we were asked to develop base line financial projections of the fund over the ten-year period from 2003 through 2012 using 2002 as the baseline as well as estimates of the financial impact of Philhealth's plans to:
- improve the benefits;
- restructure its premium contribution program; and
- cover a greater percentage of the eligible population.
Tthe stated required outputs for this project were projected benefit payments, projected contributions and projected investment income and fund balances for the next 10 years under various scenarios. In addition to the projections, an actuarial opinion as to surplus maintenance requirements as well as various recommendations in aid of maintaining actuarial soundness (e.g. required monitoring reports) were provided.
ACTUARIAL STUDY ON THE PROPOSED
REVOLVING DRUG INSURANCE FUND (RDIF) OF A
MUNICIPALITY IN EASTERN VISAYAS
The objective of the project was to provide a preliminary basis for evaluating the long-term financial viability of the Revolving Drug Insurance Fund (RDIF) in a municipality of Southern Leyte. In particular, the expected output of the project was an assessment of the cost for reimbursing drugs under the proposed RDIF.
ACTUARIAL EVALUATION OF THE HEALTH
INSURANCE PROJECT OF A CITY IN MINDANAO
The purpose of this project was to determine the appropriate premium for the utilization of the city’s health care benefits. In addition, it was considered to be an important aspect of this review to compare the utilization rates for the different benefits according to various categories of the enrollees since utilization of benefits by the enrollees varied depending on their economic class, the family physician and local hospital they selected, the municipality they belonged to, and as to whether the beneficiary was the principal enrollee, the spouse, a dependent child, or a dependent parent.
Analysis of the utilization rates based on various categories was helpful to the city’s Advisory Council in monitoring benefit availments and in formulating new policies and guidelines to identify and control unnecessary utilization. Also, showing the average family sizes of the enrollees helped determine whether or not the per family “capitation” system was equitable.
ASSISTANCE IN THE ESTABLISHMENT
OF
A
HEALTH CARE PROVIDER BY A PRE-NEED FIRM
The objective of the project was to provide technical assistance in the establishment of a health care provider by a pre-need firm.
The scope of work included product development, including product design, product pricing and financial forecasting. It also included product implementation: contract review, actuarial procedures for valuation, drafting of underwriting procedures and claims administration processes.
|
Copyright © 2008 Solutions, Incorporated - Global Vision, Local Wisdom / All rights reserved. Powered by SSM
