Stop-Loss Audit Uncovers $1.1M in Missed Reimbursements for Large Public School District

Challenge

When Hylant’s Employee Benefits team took over as broker for a 3,200-employee public school district, it identified a costly oversight that had gone unnoticed for years. The client was self-funded with a carved-out pharmacy benefit manager (PBM). During onboarding, we reviewed past stop-loss reimbursements and noticed that all payments matched the high-cost claimant reports from the medical third-party administrator (TPA) exactly—none of which included prescription drug claims.

Given the group’s size, it was highly improbable that no prescription drug claims had exceeded the stop-loss threshold. We immediately flagged the issue for further investigation.

Solution

Before bringing the issue to the stop-loss carrier—who also acted as the group’s medical TPA—Hylant requested several years of high-cost claim reports from both the TPA and the PBM. We wanted to confirm whether any prescription drug claims should have qualified for reimbursement under the stop-loss policy.

Our audit confirmed that many high-cost prescription claims were eligible but had never been submitted. Although the stop-loss contract clearly covered both medical and pharmacy claims, the carrier had never combined the two sets of data for reimbursement purposes.

Once we confirmed the gap, we shared our findings with the carrier. They acknowledged the mistake and agreed to process the missed reimbursements. Hylant also negotiated better contract terms and lower premiums going forward to prevent the issue from happening again and reduce overall plan costs.

With Hylant, expert guidance leads to smarter strategies and stronger contracts. Our proactive approach helps organizations uncover savings and protect their benefit plans.