The challenge
While reviewing a client’s claims, a Marsh Agency client advisor and a Planning and Analytics for Total Health (PATH) clinical consultant noticed that a stop-loss claim may have been understated.
Initial data suggested that claims for one member had not been reported and combined correctly. That raised questions about whether the insurance carrier had accounted for all applicable claims, including those incurred when the member was covered as both an employee and a spouse.
The solution
The client team asked a data analyst to review the claim data. The analysis indicated that the carrier had not properly combined the member’s claims, which resulted in an understatement of total claims.
The team shared its findings with the carrier and showed how the claims may have been combined incorrectly. The PATH team’s analysis also gave the client team the information needed to encourage the carrier to look into the issue further.
The result
The carrier re-evaluated the claim data and confirmed the oversight. As a result, the client recovered $70,000 in stop-loss claims. The resolution recovered funds for the client and reinforced the importance of accurate claim data management in the stop-loss process.
Results may vary by client and are not guaranteed. Claim determinations are subject to carrier review and policy terms.
