Challenge

As year-end approached and the insurance renewal cycle began, the stop loss provider notified the employer that it was going to exclude ("laser") that claim from the renewal, meaning that unless the entire claim was received, properly audited and paid before year's end, the stop loss insurer would not reimburse the company for the claimant, and the employer would become responsible for the entire cost of treatment.

Solution

The Hylant service team took a two-pronged approach, working with the client to determine how it would fund the claim if it became necessary to do so, as well as negotiating with both the primary stop loss provider and the secondary reinsurer to obtain a 90-day extension to the end-of-year deadline.

In addition, Hylant immediately began making almost daily calls on behalf of the client to the medical facility to obtain the claim documentation; nothing could be resolved without it. Finally, the administrator received the claim detail for all 300 pages.

But the team went one step further. With consent from the client, the stop loss provider and the client's PPO network, Hylant approached the hospital to see if a single-case agreement could be negotiated for the claim. Ultimately, the medical provider agreed. Charges were discounted an additional 35%, reducing the total claim amount by more than $1 million.

The claim was settled within the extended 90-day time frame. The stop loss provider benefited from the 35% discount. The employer paid only its specific stop loss deductible and also benefited from an improved stop loss loss ratio, which will benefit future renewal negotiations.