Medical Management

High-cost claimant review recovers $800,000.

Client Profile

National retailer with more than 10,000 employees covered by a self-funded plan.


This retail client had two employees with high-cost claims that met the specific deductible for the year. The retailer should have been assessed only one deductible for each employee; however, because of the carrier’s process for adjustments, the client was charged deductibles for these members in two separate contract years. This error resulted in $800,000 of additional cost to the client.


As part of our medical management services for self-funded clients, we track and analyze claims paid for high-cost claimants and often recover costs that could easily be overlooked if not for this kind of careful review. In addition to analyzing the data, we maintain contact with the carrier or TPA to ensure claims are submitted to the stop loss carrier in a timely manner and the specific deductible is charged in the appropriate contract year.


We spent more than four months negotiating with the stop loss carrier disputing the additional charge and ultimately convinced the carrier that these claims were adjustments and not new claims in the new year. The client recovered $800,000 that was incorrectly charged by the insurance company.