QVI Risk Solutions Inc.

Services We Offer

Employers having 25 or more employees with a history of stable claims experience may find self-funding an attractive alternative to traditional insurance coverage. The self-funded employer assumes the health expenses risk in exchange for keeping and managing the health premium dollars, which were normally allocated to the health insurance carrier. Stop loss protects the employer from catastrophic losses.

Self-funded health plans have several advantages over the traditional insurance system. Self-funded plans can be tailor-made to provide specific benefit levels that meet each employer’s individual objectives.

QVI is a leader in providing self-funded services. Our experienced staff takes pride in providing outstanding service and a commitment to exceeding the expectations of our clients.

QVI, as a third party administrator (“TPA”), offers a high level of expertise in providing administrative services to:

Traditional insurance carriers,
Other TPAs,
Larger groups usually with 50 or more employees that self-fund their employee benefit programs, and groups of all sizes that self-fund dental and/or vision or provide other benefits such as FSA, HRA or MERP

Examples of administrative services include claims processing, customer service and enrollment eligibility functions.

TPAs are responsive and provide close personalized service. Their flexibility and efficiency allows maximum opportunity for cost-containment and oversight. Customization and compliance support the needs of employers and employee groups.

QVI will assist the broker and employer in every step of the implementation process to assure a seamless transition. Click Brokers & Consultants to see the wide range of services available when choosing QVI as your TPA partner.

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In the traditional insurance market place the employer will provide employee health coverage by purchasing a non-flexible package of benefits at rates established by the insurance company. Profits are not shared by the insurance company; however losses most often result in a rate increase to the employer at renewal. Self-funding offers the employer an alternative to traditional insurance.

Instead of paying premiums to the insurance company the employer deposits the funds into a bank account specifically designated to pay the health claims for the employees and their dependents. The employer may also purchase stop-loss insurance to set a dollar limit on specific health claims and an aggregate maximum providing a known dollar liability for the entire group. The employer typically selects a TPA to administer the plan.

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Self-funding offers the following advantages to the employer:

Flexibility to design plan benefits to meet the specific needs of the employer.
Money previously paid in premiums to insurance companies can be used to increase company cash flow. Interest on the funds stays with the employer.
Lower administrative costs compared to traditional insurance companies.
Enhanced personalized service to employees and employers.
The option of excluding expensive state-mandated benefits in their plan design as self-funded plans are subject to Federal laws and regulation (ERISA, HIPAA) and not state regulations.
Flexible stop-loss options allow the employer the choice of risk level for which they feel comfortable.
Claims experience includes only the company’s employee base and not pooled with other employers that may have poor claims results. If during the plan year the company has good experience the employer retains the funds not used. Should higher than expected experience occur, stop-loss insurance will protect and limit the losses.
Increased choices in PPO networks and Pharmacy Benefit Managers (PBMs).
Statistical information is available to the employer in both standard or client specific formats. This assists with tracking the effectiveness of the current plan and identifying modifications that could achieve even greater cost savings in the future.

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  • Claims Adjudication, EDI, Claims Edits
  • Plan Building, Plan Documents, Policies and Employee Benefit Booklets
  • Identification Cards
  • Stop-loss Insurance
  • Pharmacy Benefits Management (PBM)
  • PPO Networks
  • Out of Network Claim Settlements
  • Subrogation Cases
  • Transplant and Cancer Care Centers of Excellence
  • Utilization and Case Management
  • Custom Reporting

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