Within the Medical Loss Ratio (MLR) Division, ER has accumulated some of the leading experts from across the country in the examination and analysis of MLR filings. Our sole focus is providing first class MLR-related services to state and Federal regulators. Since 2017, our MLR Team continues to be contracted with The Center for Consumer Information and Insurance Oversight (CCIIO) to perform all MLR examinations conducted on behalf of the Federal government. Our MLR Team has also assisted numerous states in the performance of MLR examinations, largely assessing MLR filings in compliance with the same federally mandated rules and requirements.
Through our extensive experience in conducting MLR examinations, ER has developed the expertise and skills necessary to understand the regulation, technical guidance and other MLR reporting and rebate requirements, allowing it to provide a broad assortment of assistance to state regulators.
MLR Services to Regulators:
- Performance of MLR examinations in accordance with 45 CFR Part 158, including compliance with the NAIC MLR Examination Reporting Instructions or other state specific MLR rules and requirements
- Development of specific MLR examination programs for state examiners
- Training of examiners on the nuances of performing MLR examinations
- Assisting in the design and execution of MLR examinations performed by states in a manner that ensures acceptance by CCIIO
- Identification of companies exhibiting a high risk for inaccurate MLR calculations and/or underpayment of MLR rebates
- Identification of high-risk components within a company’s MLR calculation
- Assessment of proper market classification in accordance with the federal method of counting employees for the determination of group size, or the state counting method, if applicable
- Assessment of quality improving activities (QIA), including identification of overhead/indirect costs improperly classified as QIA, and determination of the reasonableness of intercompany cost sharing transactions
- Interpretation of MLR regulations, CCIIO technical guidance and MLR Filing Instructions
- Assessment of pharmacy benefit manager (PBM) service agreements and verification of proper removal of spread pricing for prescription drug transactions, manufacturer rebates and other price concessions from incurred claims
- Assessment of the applicability of MLR specific internal controls that could be leveraged to reduce substantive testing of MLR processes and balances
- Integration of MLR examination procedures for Medicare Advantage or Medicaid lines of business
Craig has 28+ years of experience in audit and insurance company examination services. In addition to…
