High-Cost Claims Management: Cracking the Code


Learn what data is important and why in evaluating your health claims                                                                                                                                                                                                        

Risk Managers May Provide a Different Perspective When Reviewing Health Plan Data

Have you looked at your health plan data lately? How about through the lens of risk management? You might be surprised at the story it is telling you.

Analyzing plan members’ medical and pharmacy claims data is a task most often left up to your human resources team, carrier, or broker. But today’s risk management pros can add data analysis to their list of responsibilities.

Data driven accountability can help your organization control health care costs and improve employee health — take on a strategic role and let your skills drive impact.

High-cost claims are one of the top expenses facing higher education. The 5 tips below will help you take the first step toward becoming a risk manager who can drive savings and protect your institution with this transformative risk management approach.

Analyze Medical and Rx Claims to Find Cost-Savings Opportunities

  • Look at data proactively throughout the year.
  • Review claims from financial and clinical perspectives.
  • Maintain a rolling 24 months of historical data and a log of all plan changes.
  • Compare prior renewal projections with actual experience.
  • Request renewal projections from your carrier.
  • Analyze claims data monthly to identify cost-savings opportunities for your plan.

Benchmark Your Plan to See Where You Stand Competitively

  • Ask your broker for benchmark data to compare your plan to other organizations and ensure you are as competitive as possible.
  • Utilize local, regional, and national benchmarks to review:
  • Average annual cost for employees
  • Average monthly employee contributions
  • Deductibles, copayments, coinsurance, out-of-pocket maximums, etc.

Leverage New Pharmacy Benefit Savings Opportunities to Reduce Costs

  • Consider a tiered formulary design to help prevent unexpected expenses and reduce overall prescription costs for you and your plan members.
  • Evaluate the strength and transparency of your pharmacy benefit manager (PBM) contract by requesting an assessment from your broker.
  • Curb specialty drug prices by implementing a patient assistance program (PAP) that offers copay assistance and/or financial-based assistance for your plan members.
  • Educate your plan members on where to find rebates and coupons for the most cost-effective prescriptions and services.

Implement Disease Management Strategies to Impact High-Risk Plan Members Who Are at Greatest Risk

  • Review claims often — 20% of your population accounts for 80% of your costs.
  • Implement a biometric testing program to improve health outcomes.
  • Utilize nurses to communicate peer-to-peer with your insurer’s case management staff for timely high-cost claims identification and intervention.
  • If you have a wellness program, revisit your strategy and make sure the program meets your goals for return on investment, true employee engagement, and positive outcomes.

Explore Alternative Stop Loss Vendors

  • If your current stop loss vendor is already predicting delays in your renewal data, explore additional vendors in your RFP process.
  • If your company is on a self-funded plan, determine the financial stability of your stop loss coverage provider and make sure the carrier is vetted, stable, and financially sound.
  • Review the carrier’s contract terms, coverage definitions, lasering, and rate caps to make sure they fit with your company’s needs.

Viewing Your Health Plan Through a New Lens Can Pay Dividends

Look at your health plan through the lens of data and accountability. Then see where it takes you. You may find yourself in a critical strategic role that will help sustain organizational growth and health in the years ahead.

The rise of health care costs can feel inevitable. But risk management professionals who understand and leverage data will play an integral part in driving healthier outcomes for their organizations — both on the bottom line and at the member level.


By Anne K. Bowen, MBA Fellow, Indiana State University; Secretary, Indiana Commission for Higher Education; Advisor, Apex Benefits

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