High Cost Medical Claims Consulting
Medical Micro-Consulting for Employers and Brokers
High-Cost Claimant Profile with recommendations
"What does our current high-cost medical and Rx claims profile look like, and what can we do about it?"
5% of Health Plan Members drive 53% of its costs
The top 1% of people drive 25% of costs.
For one plan of 10,000 members costing the employer sponsor $50 million: 300 people account for $28 million. Understanding who is high cost this year, and who will be high cost next year will help shape critical medical cost strategies.
understand the conditions driving your costs
Where should you focus to mitigate high-cost claims?
Understanding an employer's High-Cost Claimant Profile can help prioritize next year's plan design changes, point solutions and carve-out strategies.
high-cost medical & Rx Solutions
Condition Management
Condition Management
Condition Management
High-cost claimants usually have complex medical needs. Members with diabetes need specific solutions for diabetics. Members with cancer need cancer-specific strategies. Likewise for orthopedic surgeries, behavioral health conditions, cardiac care, asthma support and reproductive health.
Virtual Care
Condition Management
Condition Management
High-cost claimants cases benefit from: more frequent interactions; a greater diversity of types of providers, and; access to expert medical advice and guidance. For those with complex conditions, the value of virtual care and telemedicine is even more significant.
Care Management
Condition Management
Care Management
High-cost claims analytics can help employers determine what care management carve-outs make senses. Care management carve-outs are increasingly in demand for certain chronic conditions, post-op care; high-risk pregnancies; pre-term infant home care; cancer hospice, rare diseases and many other clinical scenarios.
Cost Management
Place of Service
Care Management
Employers are looking to pay a "fair and reasonable price" for services delivered. Cost transparency is a hot topic in the self-insured employer space. Up charging, overcharging and duplicate billing are often a signifiant concern for many employer health plans.
Place of Service
Place of Service
Place of Service
Considerations for plan design, medical care carve-outs solutions, provider narrow network strategies and Centers of Excellence can be informed by an employer health plan's high-cost claimant profile.
Plan Design
Place of Service
Place of Service
Self-insured employers have some discretion over coverage for certain medical services. Whereas all employers want best outcomes for their health plan members, plan design this year can shape claims experience next year.