Health and Welfare

HealthcareGood Health is Good Business
A successful employee benefit plan reinforces the plan sponsor’s business objectives around such issues as recruitment, retention and productivity. A well-designed program provides needed and appropriate access to quality care which in turn leads to improving the covered population’s health status, productivity, absenteeism and quality of life.

Cambridge’s health and welfare practice offers an all-inclusive range of benefits services for:

  • Medical
  • Pharmacy
  • Life
  • Disability
  • FMLA
  • Vision
  • Dental
  • Stop-loss
  • Section 125 Flexible Benefit Plans
  • EAP
  • Consumer Directed Health Plans (CDHP)
  • Voluntary benefits

We are industry leaders in the areas of vendor selection including management, audit and compliance, analytics and risk management, and wellness and disease management strategies. Our unique expertise includes forward thinking clinical initiatives, co-morbidity of behavioral and physical health and the behavioral science connected to proper messaging and engagement of participants.

We have extensive experience with Multiple Employer Associations (MEWA), Professional Employer Organizations (PEOs) and Captive Insurance Entities.

StrategyCambridge works with each client on a proactive and forward thinking basis. We begin our engagement with a meeting to establish and document overall and specific goals, objectives and needs for the forthcoming 12-18 months. Our goal is to create knowable outcomes around administrative, compliance, financial and strategic results. We hold regular meetings to update status as well as continuously recalibrate and document baselines, benchmarks, means and methods of measurement.

Services include:

  • Creating benefits strategies which reinforce goals around human capital such as recruitment, retention and productivity.
  • Advice on market and similar business benefit trends as well as recommended alternative benefit designs or delivery systems as dictated by emerging plan costs or benefit practices.
  • Technical expertise and strategic support so that the client can continue to develop, implement and administer forward thinking program changes.
  • Guidance on emerging financial, administrative, regulatory and industry considerations.
  • Educate and communicate initiatives directed to the senior management team and/or benefit plan participants.
  • Develop, implement and help manage needed timelines for decisions around program changes, open enrollment, financial quotations, renewals and other significant events.
  • Discuss and coordinate information with other consultants employed with the client
  • Assist and advise in preparation of “request for proposals” for vendors and/or services necessary to implement benefit plans.
  • Aid the client in establishing the foundation and working environment for long-term partnership with vendors.
  • Advise the client and act as a liaison in contract negotiations and renewals with vendors including coordination of reporting and overall vendor management issues.
  • Develop, document and implement performance standards for vendors (including Cambridge). Areas for consideration include financial cost and accuracy, administrative quality and accuracy, as well as overall customer satisfaction.
  • Develop and utilize appropriate monitoring tools for compliance with performance standards.
  • Negotiate vendor agreements which properly assign, limit and transfer legal, financial and administrative liabilities.

Audit and ComplianceCambridge prides itself on our use of unique data hierarchies and critical thinking in the areas of audit and compliance. We work diligently with our clients to explain administrative, financial and strategic implications of the law and emerging regulations. We proactively offer analysis and interpretation on both the intended and unintended consequences for plan sponsors. We provide tactical and strategic thought as well as advice for each client based on the specific circumstances.

Our Applied Quantitative Analytics (AQA) merges the talents of our diverse group of experts with a proprietary audit tool. AQA identifies aberrant clinician utilization, referral and billing practices. Claims are indexed by service type and modality, correlated to reimbursement mode by provider and adjusted to local practice patterns. AQA identifies and quantifies the causes and costs of “claim leakage” and the effects of provider revenue cycle enhancement. It examines clinical practices, costs and outcomes by provider.

AQA’s capabilities make it an invaluable audit tool which brings transparency to provider behavior and carrier management skills. It enables recoupment of previously made inappropriate AQA payments and also identifies efficient, high quality providers for use by plan sponsors, participants and network entities. AQA’s value to clients will continue to grow as Health Care Reform results in provider network reconfiguration and CDHP requires increased information to be placed in the hands of the participant.

Additional audit and compliance services include, but are not limited to:

  • Authoring and release of legislative and regulatory updates.
  • Provide assistance and advice with review of benefit programs on a continuing basis to ensure compliance with federal requirements and adequacy of benefits with respect to other plans.
  • Provide information on pending or new legislation and changes in tax law, as well as benefit and funding trends that may affect the benefits program, applying assumptions to various scenarios.
  • Audit, develop and document appropriate client policies and workflow for regulatory compliance.
  • Conduct administrative, operational and clinical vendor audit, which also includes review of data security as well as internal audit and controls.
  • Perform discrimination testing for insured and non-insured arrangements.
  • Advise and assist the client with writing plan modifications and new plans, submitting written reports and other documents as required by the Federal Government.
  • Assist with required filings such as Form 5500s, ERRP and minimum credible coverage.
  • Review all plan documents, contracts, insurance policies and employee communication for accuracy, applicability and consistency.

Cambridge’s team consists of actuaries, clinicians, economists, doctorates in public health, revenue cycle enhancement specialists and other benefit experts. We utilize proprietary data management tools to perform multi-disciplinary and integrated population based analysis.

We approach our large, complex clients as if they are, in fact, the insurer of their covered population. We assist by asking and answering detailed and non-standard questions designed to assess, abate and manage risk. Cambridge takes great effort to identify the underlying causalities of risk, costs and liabilities with particular focus on the “at risk” and “of need” segments of the clients covered population who drive a disproportionate percentage of costs.

Consideration is given to both chronic care underlying conditions which act as “complicators,” and the identification of emerging large claims as well as the management of existing large claimants. We assess, quantify and create integrated solutions regarding risks and costs that apply across multiple plan types. An example of this work is recognizing the cost and issues surrounding high cost medical claimants who are also subject to EAP, FMLA and disability benefits.

Our technical services include:

  • Data collection and analysis of risks, costs, and liabilities utilizing a unique hierarchy of varying data sets.
  • Conduct internal actuarial and clinical analysis of claims experience, premiums paid, claims reserves and fund requirements as requested.
  • Establish appropriate accrual rates and reserves for all self-insured plans as well as determine appropriateness of rates and reserves put forward by carriers for insured arrangements.
  • Maintain records of financial and claims experience, condition, and progress of the client’s plans. Provide the client with quarterly reports.
  • Development of customized reporting packages specific to individual client needs.
  • Analyze and integrate all available clinical data from the sponsored programs to establish proper risk and cost baselines then project the possible effects of various health risk management tools.
  • Assess the client’s tolerance for risk and then develop corresponding risk management strategies in order to lower plan costs and improve predictability. Appropriate risk management tools may include provider network and clinical management, plan design change, alternate contribution structure, multiple rate tiers and benefit classes, knowledge of carrier underwriting practices and state underwriting requirements, product composition and selected funding arrangement.
  • Analyze the value of various network and clinical management alternatives around cost, value, appropriateness and results.
  • Create needed ROI models which quantify and qualify the value of such factors as satisfaction, absenteeism, turnover and morbidity.
  • Provide needed Medicare Part D attestation and accompanying subsidy calculations.
  • Perform needed Discrimination Testing for IRC Sections 105, 125 and 129.
  • Calculate and provide FAS 106 and 112 liability studies.
  • Prepare alternate funding analysis including the possible use and implementation of a Captive entity, PDPs and other available solutions.

We have a comprehensive review and assessment process in place for merger and acquisition due diligence. It includes:

  • Data Collection for census, SPDs, reports, and financial results.
  • Assessment of Plan Compliance with applicable laws.
  • Review of Plan Communications.
  • Evaluation and Projections of Accounting and Funding costs and liabilities pre and post-acquisition.
  • Analysis of alternatives for merging and eliminating plans.
  • Analysis of benefits which must be preserved based on applicable IRS rules.