Uncertainty is an inherent part of using self-funded insurance. How much your group will spend on claims in a given year depends on factors that are largely outside your control. If members require more services than you expect, or if the cost of those services jumps dramatically, maintaining adequate cash flow can turn into a financial tightrope walk. At least you can get reimbursed for catastrophic claims, thanks to your stop loss coverage.
But claims can’t be reimbursed overnight. Paying those hefty bills upfront and waiting for payment often causes cash flow issues for organizations. If your stop loss carrier issues payments quickly, those influxes should help keep you afloat. Think of cash flow like a domino chain. Each stop loss claim that’s paid quickly helps keep the operation moving forward. A claim that’s not paid on time creates a gap that could stop the entire chain in its tracks.
Clients and carriers should be on the same page here. It’s in the carrier’s best interest to pay claims efficiently because that’s what the client needs. Identifying obstacles to speedy claim payment and working together to avoid them is a goal that both sides should work toward.
From the carrier’s perspective, any number of issues can slow down claims payment. Often, a delay in reimbursement happens because the client doesn’t submit all the information that the carrier needs. Claims can’t be reviewed and paid until all the required information is included with the claim, so the reimbursement process will be paused until the carrier receives everything. (A claim that is accompanied by all required information is called a clean claim. Clean claims get paid efficiently!)
It’s not only incomplete claims that cause holdups. The issue of claims that are incurred during coverage lapses is especially thorny. A member submits a large claim, the self-insured client pays and then turns to its stop loss carrier for reimbursement – only to find out that a late premium or other oversight means that the client wasn’t covered during the period in which the claim was incurred.
Sometimes, it’s the specific member or claim type that’s the problem. A member submits a claim incurred by one of his or her dependents but the patient is not eligible for coverage under the health plan, or the service that the member received isn’t covered by the plan. Those issues shouldn’t occur when a self-insured employer works with a third-party administrator because the TPA should communicate with the employer about what people and services are covered – but mistakes happen.
As the client, you should never have to guess about what documentation the carrier needs for claim processing, or whether the claim will be approved or denied. Answers should be found in the stop loss contract and other plan documents, and clients can always get help by contacting their TPA and/or brokers.
Your organization relies on quick reimbursement for catastrophic claims, and our business relies on making that happen. That’s why Stop Loss Insurance Brokers, Inc. is committed to working with the client and the stop loss carrier to assist in processing claims as quickly as possible. Our team works behind the scenes to make sure that we and the stop loss carrier have all the information that we need to make your reimbursements happen. Contact us with any questions or concerns about your stop loss insurance needs.