Danvers, MA 01923 Full-time The Senior Claims Examiner is responsible for the following duties within a dedicated unit serving the HMO Reinsurance/Provider Excess, Stop Loss and Reinsurance Claims needs of our clients. Extensive knowledge and experience adjudicating accident and health claims for traditional medical, specific and aggregate excess, HMO reinsurance or provider excess claims. Audit… Continue Reading →
Responsibilities
At Northshore, Ms. Gariepy reviews and supervises the handling of casualty claims on behalf of excess insurers and reinsurers. She is specifically responsible for the oversight and management of liability and workers’ compensation excess claims for governmental entities and assists in directing our governmental entity program.
Professional Experience
Ms. Gariepy has 30 years of experience managing multi-line casualty and training units, as well as being in-house claims manager for insurance companies handling claims in multiple states. She has worked on the NLC Mutual claims management program in increasingly responsible roles for 22 years.
Conducts and manages reinsurance claim audits, coverholder reviews, public entity pool reviews, self-insured and TPA claim reviews. Mr. Betz has been active in the self-insurance industry since 1982 with 13 years of claims supervisory and management experience, including field office management in a multi-line claims office. He has extensive experience in adjusting property, casualty and workers’ compensation claims.
Mr. Ives is an internationally recognized expert in the insurance industry and has been a strategic advisor providing consultation to many Northshore clients on technically challenging matters such as reinsurance arbitration and litigation. He has provided claims management services, including insurance and reinsurance claims reviews since 1982 and has handled claims since 1979. Mr. Ives is a frequent speaker at industry seminars and has published articles on insurance and claims topics.
Mr. Scerra has provided claims management services, including insurance and reinsurance claims reviews, since 1977; his management and technical claims experience includes primary and excess property and casualty, and accident and health insurance. At Northshore, he conducts underwriting, premium and claims reviews of managing general underwriters and carriers on behalf of issuing carriers and reinsurers. He also has been called upon to provide expert witness evaluations and testimony in arbitration and litigation matters.
Mr. Murphy has worked in the field of medical claims handling and management since 1981, holding various positions of increasing responsibility in both field claims units and corporate home office settings. His experience also includes marketing health, managed care and indemnity products and, since 1990, underwriting these products. Mr. Murphy manages the Northshore Accident & Health Division staff, who review stop loss, provider excess and HMO reinsurance claims and conduct audits on behalf of domestic and international reinsurers.
Northshore’s highly qualified associates and consultants and experts provide insight to insurance arbitration and litigation that is often sought out by attorneys from insurance defense litigation divisions of even the most seasoned law firms. Our services are provided by professionals holding designations including JD, CPA and CPCU. As insurance and reinsurance claims become larger and more frequently contested, these larger losses have a significant impact on a company’s bottom-line. It is therefore, critical to engage well-qualified arbitration.
On behalf of risk-taking clients, we perform complex audits of the eligibility, claims and operations of life, short term disability and long term disability programs.
These audits include verification of eligibility under the subject life and/or disability coverage, evaluation of complex claims, and detailed overviews of all aspects of operations pertaining to the programs insured.
The observations and findings identified in these audits are measured against industry standards and practices, which allows us to provide recommendations to strengthen the audit subject’s operation, thus allowing a more successful partnership between the audit subject and its risk bearer.
We are regularly retained by Municipal Pools; Risk Retention Groups (RRGs); Captives; Domestic Insurers; and Reinsurers to review captives and their service providers (TPAs) to evaluate the quality of claims handling, reserving and outward reporting as compared to the basic tenets of proper claims handling and agreed upon contractual metrics. Classes of business include workers’ compensation, general liability, police and public officials liability, APD, property, and employee medical benefits.
We also act as the reinsurance claims department for a captive reinsurer, managing and reporting on hundreds of workers’ compensation, liability and property claims.
Some form of monetary value, or other economic loss is an element in many insurance claims settlements. Catastrophic Damages, by definition, exceed damages that typically would be classified as “normal” damages. They typically involve damages that cover a more widespread geographical area from a single event or class of business than do other types of damages.
Catastrophic Damages affect damaged parties or entities to different degrees of Economic Loss. For example, after the tragic events of 9/11 we worked with global insurers and reinsurers and conducted numerous file and field claim and data audits to sort out and report the actual and potential effects of workers’ compensation losses to their respective layers and blocks of business.
Put simply, once the event has occurred, the client needs to know what the future economic exposure of the loss will be, and we can help with that determination.
Our insurance and reinsurance experience allows us the ability to break the process down into its comprehensible components and provide the client the meaningful data and information necessary to properly reserve for Economic Damages.
Northshore’s experienced Health and Property/Casualty consultants and experts provide insight to insurance arbitration and litigation that is often sought out by litigators from the insurance defense litigation departments of even the most seasoned law firms.
Northshore’s Expert Witness Support services are provided by highly qualified associates and consultants, who hold respected professional designations including JDs, CPAs and CPCUs.
Northshore’s Expert Witness Support services include:
Responsibilities
At Northshore, Ms. Zurek manages a staff of auditors who audit and review specific excess, HMO Re and Provider Excess claims. She is also responsible for the supervision and training of new MEF employees, and manages the run-off of large reinsurance programs including disability, Workers’ Compensation, and life insurance claims. Ms. Zurek conducts aggregate excess claim reviews and serves as a consultant for Medical Excess Stop Loss claim issues within the industry and provides litigation and managed care support. Ms. Zurek is proficient in establishing claim reserves and serves as an industry expert in this area for several clients.
Professional Experience
Ms. Zurek, who joined Northshore in 1991, began her insurance career in 1978. She has technical and management experience in administration of group health benefits. Her experience includes claims adjudication, claims department management, training protocols, and development and implementation of internal audit processes.
Northshore will work with you to deliver a visionary growth plan to protect or enhance an existing position or successfully develop a new strategic position, which ensures its success. We have real and far-reaching experience helping companies resolve their insurance and reinsurance claims and operational challenges and optimize opportunities. Class settlements due to catastrophic damages affect damaged parties or entities to different degrees, covering widespread geographical area. Our insurance and reinsurance experience allows us to break the process down into its comprehensible components and provide the client the meaningful data necessary to properly reserve for these damages.
For the risk-taking market, we conduct claim department management studies, assessing the quality and efficiency of systems and procedures and their impact on reporting; reserving; and resolution — “the 3-Rs.”
Additionally, we review ceding companies and their providers of service (TPAs) to assess staffing; underwriting; premium administration; technical claims handling; commutation possibilities, and other items of interest to our risk-taking clients.
We represent the interests of domestic and international excess carriers and reinsurers to ensure that the underlying exposures are recognized promptly and handled appropriately.
We visit service providers contracted by these risk-takers and are often asked to monitor the handling and reserving of workers’ compensation claims and assist in their final resolution. We also manage reinsurance exposures generated by workers’ compensation carve-out business.
The experience faced by municipalities and other governmental agencies such as police departments, are unique, and they require an exceptional knowledge base to recognize and evaluate strategies and exposures. Our staff has handled the claims that arise from these exposures for more than 30 years.
On behalf of risk-taking clients, we review the designated service provider’s management, reporting and resolution of claims or law suits associated with our clients’ business.
These service providers have been delegated certain authorities, such as claims investigation, settlement and payment; subrogation and salvage recoveries; or litigation management. We review these authorities as relates to agreements, guidelines and structures imposed upon them, as well as industry-best practices.
Many of the service providers have either developed or purchased sophisticated claims management systems which allow remote access. With appropriate access, we have been completing more and more of the claim reviews remotely, saving our clients thousands in travel-related expenses.
On behalf of risk-taking clients, including Lloyd’s Managing Agents, London Market and Domestic (U.S.) Insurers, we review the production entity’s management of business to our clients.
These entities have often been delegated certain authorities, such as underwriting, premium collection, and claims handling, and we review these authorities as relates to agreements, guidelines and structures imposed upon them, as well as industry-best practices.
Generally, we see our role as an extension of the risk-taking client. We are often tasked with securing and reporting information; reviewing underwriting, compliance and claim records; and forming opinions based upon what we have reviewed.
Utilizing our proprietary claim system, we incorporate Medicare and/or Medicaid fee schedules into a table of valuations based on excess policy terms. We produce fee values to be applied during the claim adjudication process. Additionally, we offer pre-adjudication comments that highlight policy limits, highlight potential duplicates, and identify treatments and conditions that may require additional review to determine eligible expenses.
We evaluate and verify excess of loss medical claims and report findings to clients and reinsurers. We recommend reimbursements on behalf of our clients acting as their in-house claims department.
Our results have saved millions of dollars for our clients by confirming policy terms, conditions and limitations are applied correctly based on the underlying risk.
Utilizing a well-trained staff of experienced managed care claims professionals, supported by a proprietary Claims Processing System, we quantify, verify and reprice excess claims. Our evaluation and adjudication experience in this class allows us to assist in the drafting of policy language and to analyze and resolve coverage issues. We also conduct implementation visits and administrative and technical reviews of managed care providers and third-party administrators, as well as HMOs and other health plans.
We monitor and evaluate the handling of self-funded employer stop loss specific claims, establish reserves, and report to our clients and reinsurers. We recommend reimbursements and manage the claim payment process on behalf of our clients, acting as their in-house claims department. We also provide additional capacity to excess claims departments with claim back log support utilizing client claim platforms or our own reporting tools.
We offer premium audits at the request of the risk-bearing entity. Ours comprehensive audit includes an understanding of the audit subject’s premium administration and audit samples to test that the premium received accurately traces to census.
Reinsurance audits are most often commissioned by the “Lead Reinsurer” on behalf of the market. We confirm the business mix underwritten to the reinsurers, and that the business complies with the intent of the parties to the reinsurance agreement(s). Most often, the audit components involve underwriting, claims and premium administrations.
We review and evaluate all phases of an MGU’s operations; including underwriting administration, premium administration, claim administration, TPA oversight, data protection and disaster recovery. Findings are discussed with the Program Manager with the goal to provide information regarding industry standards and practices, and to strengthen its overall administration.
We offer audits of specific excess claim reviews at the request of the risk-bearing entity, or as a due diligence on behalf of the Program Manager. Findings are discussed with the Program Manager with the goal to provide information regarding industry standards and practices, and to strengthen the claims administration.
It is critical for employers to have a complete understanding of the capabilities and competencies of the TPA’s administration. To that end, we work directly with employers and brokers/consultants to formulate a scope of audit that meets due-diligence requirements and concerns. These audit scopes are designed unique to the concerns and/or wishes of our client and can include one or any of the following: Claim Operational Audit, Stratified Statistically Valid Random Sample Claim Audit, Random Sample Claim Audit; Focused Top 100 Claims Paid Audit; and, Targeted Issues Audits such as Duplicate Payments, Coordination of Benefits; Eligibility; Stop Loss Submission, etc.
Since the inception of our firm, we have audited literally thousands of aggregate claims. Our role is to audit the TPA’s submitted calculation and apply the Plan Document and Stop Loss contract terms and provisions to all elements of the claim. We provide our comprehensive reporting which details our recommended reimbursement as well as all details regarding the findings.
Responsibilities
At Northshore, Ms. Keener-Borresen conducts provider excess claim reviews as well as detailed claim reviews of specific and aggregate excess claims on behalf of issuing carriers and interested reinsurers. She also assists in audits of third party administrators and managing general underwriters, and provides litigation support and contract interpretation on behalf of both insurers and reinsurers.
Ms. Keener-Borresen also provides consulting expertise on behalf of interested reinsurers regarding the management of their managing general underwriters.
Professional Experience
Ms. Keener-Borresen, who joined Northshore in 1996, has been involved in the medical insurance industry since 1988 working for MGUs, TPAs and life & health insurance companies. Her experience includes processing managed care and specific excess loss claims, assisting in aggregate audits, adjudicating claims on a variety of insurance products, including health, life, disability and international policies as well as customer and provider relations, staff training, and assisting in the development of an international claims department.
Ms. Burns manages the Claims Management unit, conducts review and analysis of medical excess, provider excess and HMO reinsurance claims on behalf of managing general underwriters, issuing carriers and reinsurers. She also often assists with Managed Care audits, litigation support, and enhancement and maintenance of Northshore’s managed care claims adjudication system.
Ms. Arsenault has worked in the insurance industry since 1990. At Northshore, Ms. Arsenault conducts reviews of carriers, managing general underwriters, third party administrators, and health maintenance organizations; verification audits of premium, aggregate excess claims, specific excess claims, and provider excess and managed care reinsurance claims. Ms. Arsenault also conducts employer-sponsored health plan administrator reviews, quality assurance reviews, as well as consulting services on contract language. She has also been called upon to assist in the run-off management of managing general underwriters, as well as providing strategic litigation assistance and testimony in litigation matters.
Mr. Ives has been involved in the insurance industry since 1983 and has been conducting a range of property and casualty reviews since 1989. His responsibilities include managing the Coverholder review staff, as well as conducting operational reviews of delegated underwriting authorities and insurance and reinsurance claims reviews. Mr. Ives is president of International Subrogation Management (ISM)-a division of Northshore specializing in analyzing employee benefit and casualty coverages and initiating recoveries for clients writing specific, aggregate and managed care excess business. Mr. Ives manages the mid-west office of Northshore and ISM located in Plainfield, Illinois.