Claims and Policy Management: What we do and why it is important

Stop loss insurance provides protection for your organization in the face of a catastrophic claim.   But, how do you know your claims are being paid correctly and your organization is being reimbursed the maximum amount? Your organization can certainly manage its own claims and policy, but working with an experienced broker is beneficial.

What is claims management?

A company, such as a broker specializing in stop loss insurance, experienced in managing medical claims with an immense understanding of health insurance will track your claims on a month to month basis to ensure your claims are properly adjudicated.

Your stop loss broker should be able to do the following:

  • Run claims from an in-house database or obtain claim data from the underlying plan.
  • Submit claims to the reinsurance carrier on a monthly basis.
  • Collect and record the reimbursements prior to sending them to you.
  • Research a denied and/or pended claim to determine the issue and ultimately obtain reimbursement from the carrier if claims are eligible.
  • Send you high cost claim report with individuals that are at 50% of the deductible.
  • Send monthly reimbursement records to show which claims have been reimbursed and which that are pending.
  • Keep open communication and work side by side with your consultant and/or underlying plan broker, if you have one.

As evidenced, there are many factors that go into successfully managing medical claims correctly.  This may not be something you have time for or want to make a part of your daily responsibilities.  Thus, hiring a broker with experience in this arena will assure your stop loss claims and policy are being handled appropriately.


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    In 2011, the top 5 most expensive medical conditions treated in US hospitals were: Septicemia, Osteoarthritis, Complication of device, implant or graft, Liveborn, and Acute myocardial infarction

    From 2010 to 2013, the number of claims that were individually $1 million or above rose by 1,000%

    In 2017 approximately 18% of the American public will purchase insurance through exchanges, radically transforming the health insurance landscape.

    In 2014, 98% of large firms (= 200 Workers) offer 1+ wellness programs to their employees.

    The most costly 1% of patients account for 20% of national health expenditures – accruing average annual expenses of nearly $90,000 per person.

    6% of firms offering fully-insured plans report they intend to self-insure because of Obamacare.

    In 2014, PPO plans remained the most common plan type, enrolling 58% of covered workers.

    In 2012, 93% of businesses with 5,000+ employees and 80% of companies with 1,000-4,999 employees were self-funded

    Massachusetts has the third-highest prevalence of self-funded insurance in the small-group market (Fewer than 50 employees).

    In 2013, the average deductible was $2,906 for individuals selecting plans from marketplaces. This compares with average deductibles of $1,135 for an individual with employer coverage.

    In 2013, the average annual premiums for employer-sponsored health insurance are $5,884 for single coverage and $16,351 for family coverage, up 5% and 4% respectively from 2012.

    From 2010 – 2013, cancer followed by chronic/end stage renal disease and leukemia accounted for the top 3 costliest illnesses.