MLR Exams

Our team of seasoned professionals are intimately familiar with the objectives and goals of conducting Medical Loss Ratio (MLR) examinations having recently performed over 60 MLR examinations of various health insurance entities performed on behalf of the Center for Consumer Information & Insurance Oversight (CCIIO) and state insurance regulators during the past several years. The primary objective of the service is to verify the accuracy, completeness and reasonableness of a health issuer’s MLR filings in compliance with the Affordable Care Act (ACA) requirements. Our team members are subject matter experts on the reporting and rebate requirements of the MLR provision of Section 2718 of the Public Health Service Act (PHSA) and the ACA, the implementing regulations, and the related technical guidance, as well as the MLR Annual Reporting Form and Instructions. Our MLR services include, but are not limited to, the validation of claims, premiums and other related adjustments; appropriateness of allocation of expenses and classifications of quality improvement activities (QIA); and the accuracy of rebate calculations and payments to subscribers.

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What We Offer

  • Examination services in accordance with NAIC and Centers for Medicare & Medicaid Services (CMS)/ CCIIO guidance
  • Consulting and training services to state regulators regarding MLR examinations and findings

For More Information 855-246-0815

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Our Core Team includes financial examiners, data analysts, actuaries and market conduct professionals. From our previous experience, the Team has the benefit of understanding high risk areas and common mistakes by insurers that may lead to the identification of noncompliance with the regulations and result in examination findings and recommendations.

Our MLR team members are thought leaders and are involved in the continual evaluation and enhancement of MLR examination procedures based on the experience gained during the MLR examination process. Our Team also has extensive experience in performing risk-focused financial examinations based upon the NAIC Financial Condition Examiners Handbook (NAIC Handbook) and statutory accounting principles making us well versed in issuer’s operational and financial practices. Our state examination and extensive MLR experience and long working relationship with CCIIO has allowed us to fine tune our approach and professional judgment used on the MLR examinations to gain efficiencies. In addition, the team has developed and delivered numerous MLR and regulatory training presentations to state insurance departments.