Managing plan costs can be challenging for employers and their HR teams.  Not only is the process of obtaining and securing the claim file in a HIPAA compliant environment necessary, understanding how to review and interpret the data is imperative to identifying those areas that are contributing to escalating costs.  The first step is to request prior plan year claim(s) experience from your TPA or carrier.  This initial review will provide valuable insights into the cost and utilization represented through paid claims.  It further establishes a benchmark for HR professionals to track and monitor progress. Subsequent files should be requested on a quarterly basis.  Ensure that your server environment can support and manage large data files.  Once you have secured the data, here are some key claim conditions HR professionals should look for when reviewing a medical claim file:

  • Claim amounts and frequency of visits
  • Provider network utilization
  • Prescription drug usage and cost
  • Other out-of-network services
  • Chronic disease management
  • Emergency room visit utilization
  • Duplicate payments

The above conditions can have a significant impact on overall plan expenses, as they can lead to increased medical costs and potentially higher insurance premiums.  There are steps HR can take to mitigate their impact. Engaging with a trained professional can also help guide you through the process.

  • Review claims for accuracy. Bill errors equate to 80% of overpayments
  • Negotiate high dollar claims with providers
  • Encourage employees to use in-network providers
  • Negotiate discounts with prescription drug vendors
  • Encourage the use of telemedicine services for non-emergent medical visits
  • Review payments to ensure payments to providers are made according to the plan’s policy
  • Promote wellness programs and education to reduce the risk of chronic conditions

These steps may can seem a little daunting but having a proactive approach and experts on your side will have a significant impact on both the company’s financial health and employee satisfaction.  By reviewing claim files and becoming an informed consumer, HR professionals can identify patterns, address potentials issues, and provide resources to employees that promote better overall health outcomes.

About the author: Wendy Bennett is the COO of  The company provides employers with the resources to better manage healthcare expenditures. Her experience as a hospital finance executive and, most recently, the President of one of the nation’s largest patient advocacy groups, provides employers with valuable insights into today’s healthcare market.