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Preferred Provider Organizations
A Preferred Provider Organization (PPO) is an organization of medical providers delivering health care on a discounted, fee-for-service basis.

"In-Network" refers to those providers who have contracts with the PPO.

"Out-of-Network" are all providers who do not have contracts with the PPO.

Plan participants have a choice of using in-network providers or out-of-network providers. Choosing an in-network provider generally results in lower copayments, deductibles and coinsurance charges. Both the member and the employer can realize substantial savings by using in-network providers.

If services are received from an out-of-network provider, generally the Plan will cover the services, but at a reduced reimbursement level.

PPOs are one of the most flexible forms of managed care, providing savings and allowing the employee the option of receiving care from any provider.

Benesight has contracts with national, regional and local PPO networks that can serve the needs of employers with both single and multiple locations. In fact, we have access to virtually any provider that a customer may choose to use.

Advantages

Vendor Integration – Benesight can work with almost any PPO vendor of your choice or one of our recommended business partners.

Provider Credentialing – PPOs use stringent guidelines in credentialing their providers, so that employees can be assured of quality care.

On-Site Repricing – Health claims received by Benesight can be repriced on-site for many PPOs and inputted directly into our claims area for processing.

PPO Benefit Plans – PPO benefit plans can be "flagged" in the system to assist in monitoring and tracking PPO usage.

Physician Directories – Physician and hospital directories for employees and employers are available for a separate fee through the PPO. In addition, most PPOs provide access to their hospital and physician network on the Internet. By accessing the PPO’s web site, employees can easily locate a network physician and/or hospital.

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Overview of Self Funding
What is self-funding?
What are the advantages of self-funding?
How does self-funding work?

What is Self-Funding?
Under a self-funded health plan, an employer assumes responsibility for paying the health claims incurred by plan participants. The employer usually purchases stop-loss insurance for protection against large, unforeseeable claims. Unlike a traditional health plan, in which an employer pays a fixed premium to an insurance company every month regardless of the amount of claims incurred, a self-funded health plan gives the employer greater control over plan costs – with some increased risk.

What are the Advantages of Self-Funding?
Self-funded health plans offer the following advantages:

• Increased Cash Flow: The employer holds funds until they are needed to pay claims. Funds can be managed and controlled by the employer rather than the insurance company.

• Cost Savings: Self-funded plans are generally regulated by ERISA and can avoid costly state-mandated benefit coverages and state premium taxes. The employer may earn interest on funds that would otherwise be held by an insurance company, and plan administrative costs are lower than those with a fully insured plan.

• Plan Design Flexibility: A Self-funded plan is not regulated by the state and, therefore, generally does not have to comply with state-required benefits. The employer can design a benefit plan that fits its benefit philosophy and cost objectives.

How does Self-funding Work?

1. The employer decides upon a plan of benefits with the assistance of a broker or consultant and Benesight.

2. Stop-loss insurance is purchased to protect the employer against catastrophic and/or unpredictable claims.

3. A plan document is prepared. The plan document contains all the benefit provisions, including eligibility, coverage and termination provisions.

4. Benesight performs eligibility and claims administration according to the plan document.

5. The employer establishes a bank account to fund the claims.

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Stop Loss Administration
What is Stop loss Insurance?
What Stop loss Insurance Coverage is Available?
Who is Insured?
Reinsurance Management

What is Stop loss Insurance?

Stop loss insurance provides the employer with financial protection against catastrophic or unpredictable losses. Under a stop loss policy, an insurance company becomes liable for claim payments that exceed certain limits called deductibles.

What Stop loss Insurance Coverage is Available?

Stop loss coverage comes in two basic types: Aggregate and Specific.

• Aggregate Stop loss Insurance protects against fluctuations in claims frequency and/or severity. It limits the overall yearly claims liability by reimbursing the employer when the claims paid for the self-funded plan, as a whole, exceed the preset limit (aggregate deductible).

• Specific Stop loss Insurance protects against catastrophic claims incurred by one individual. It limits the yearly claims liability by reimbursing the employer when the claims paid for one covered individual exceeds the preset limit (specific deductible).

Who is Insured?

A significant difference between stop loss and conventional fully insured plans is that stop loss insures only the employer; it does not insure any employee.

Reinsurance Management

Benesight maintains strategic relationships with the highest rated stop loss carriers throughout the country. Due to our national presence, employers have access to virtually any stop loss carrier and multiple types of coverage while benefiting from the most competitive rates.

Stop Loss Solutions – Benesight has access to a wide variety of stop loss products and services that include individual and aggregate coverage, an aggregating specific product, premium risk sharing arrangements, and a terminal liability option. We also have access to Managing General Underwriters (MGUs) who represent carriers that provide specific products and solutions to meet unique customer needs.

Vendor Integration – We can bill, collect, and remit monthly premium payments directly to the carrier eliminating the need to process multiple invoices and payments.

Monthly Review – Benesight will review paid claims by individual to monitor the progress of claims reaching or surpassing 50% of the Individual Specific Deductible. When necessary, we will notify the carrier of the specific details of the claimant and together, Benesight and the carrier, will closely follow the claim. The aggregate claims, if applicable, will also be tracked to ensure awareness of any approaching aggregate claims.

Renewal Review – Benesight will evaluate the stop loss pricing at renewal and ensure a fair and competitive market value for the services offered.

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Subrogation
Benesight maintains relationships with major subrogation firms to provide claims negotiations and maximum recovery efforts from responsible third-party insurance companies and other payors. These recovery professionals include experienced attorneys, property and casualty experts, registered nurses and paralegals.

Claims Referral Process – Benesight works with each customer to identify and maximize recovery efforts and manage all correspondence with employees and third parties.

State-of-the-Art Subrogation Software – Claims data is transmitted to claims recovery firms via electronic format or hard copy to evaluate claims history line by line, identifying those with the greatest third party liability potential.

Claims Negotiation – Subrogation vendors negotiate and settle claims with insurance companies and other payors.

Subrogation Reporting – Reports document the recovery process on a monthly or quarterly basis, which includes new case activity, active cases in process and closed cases with recovery results.

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