Having nurses on staff allows Symetra’s stop loss staff to deliver medical expertise and cost-containment services with a regional focus.
"It’s not just about saving money on claims," said Marien Diaz, assistant vice president of Group Benefits in Symetra Life Insurance Co.’s Miami, Fla., office. "It’s about opening the door to a variety of value-added services for our third party administrator (TPA) partners, agents, consultants, stop loss policyholders and the underlying plan participants."
Diaz is talking about Symetra Life’s medical risk consultants (MRCs)  . This team of registered nurses oversees the management of ongoing catastrophic medical circumstances, and works with underwriters in the risk assessment process for new and renewal business.
Each day our MRCs partner with TPAs to offer solutions designed to supplement the TPA’s medical-management programs. Symetra nurses act as liaisons between TPAs and our partner vendors’ managed-care programs.
The goal is to work together and deliver the best possible outcome for the management of catastrophic illnesses — everything from cancer to organ transplants.
"From the first day we receive notice of a potential claim, there are tremendous opportunities to impact the cost and quality of care," Diaz said. "Our approach to the management of catastrophic claims is designed to be a win-win outcome for all parties."
For example:
- TPAs, agents and consultants benefit by offering Symetra Life’s products and services.
- Employers benefit from having a cost-effective self-funded plan, with competitive rates and improved renewal experience.
- Plan participants benefit by gaining access to managed-care program options designed to stretch their lifetime maximum coverage under self-funded medical plans.
A Success Story
"When TPAs and the MRCs work together towards the same goal, great outcomes can be achieved on ongoing catastrophic claims," Diaz said.
She relayed a story about a notice of potential claim Symetra Life received for a premature infant born at 24 weeks gestation: "The TPA reported the case to us while the child was still hospitalized. The MRC estimated the hospital bill would be approximately $1.2 million by the time the newborn was discharged."
The hospital was part of the underlying plan’s primary preferred provider organization (PPO) network, which resulted in a 3 percent PPO discount. However, the MRC successfully negotiated an additional 22 percent discount on the bill.
Symetra Service
Diaz admits one of the main reasons stop loss clients want to do business with Symetra is the quality service we provide. "We look for ways to pay eligible claims fairly and promptly," she said. "It’s our motto."
But, as outlined above, MRCs also proactively oversee ongoing stop loss claims from the policy inception date, and work closely with claims and underwriting to make sure we never pay retail prices on claims. To learn more about everything we can do for you, use the quick links on this page, or call 1-800-426-7784 or contact your local Symetra office.
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| What Can Our MRCs Do For You? |
Case Management
Symetra’s medical risk consultants (MRCs) — a team of registered nurse professionals — deliver the following services at no cost:
- Monitor individual cases that may be at risk for exceeding the specific deductible, and then seek out discounts and cost-containment solutions.
- Answer questions regarding ongoing care.
- Provide access to our elite managed-care partners’ programs nationwide.
- Partner with TPAs to find new opportunities to further reduce claims costs.
Advance Claim Reviews
Also, we recognize that medical technological advances often pose challenging questions for claim decision-makers at the TPA or policyholder level. We pride ourselves in offering a no-surprises approach to claim reviews.
To learn in advance if a questionable claim or treatment plan will be covered under the excess loss contract issued to the policyholder, use the "Excess Loss Referral Assistance Request" form.
Our technical referral staff will work with the most prestigious independent peer review firms in the country in order to provide objective answers to the TPA’s or the policyholder’s questions.
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