The Path to Timely and Accurate Claims Payments

All roads through a Stop Loss carrier lead to paying claims. Self-funded groups purchase our coverage to help protect their finances from the impact of high-dollar claims, so with a Stop Loss contract in hand, they expect that their catastrophic claims will be paid. And as a responsive carrier that is committed to applying exceptional underwriting practices to the groups we enroll, we have committed to having the right resources in place to deliver quick and accurate claims payment.

There are, however, a number of routes to the point of payment, and I’m sure our clients would prefer the most direct. After all, these self-funded employers pay their claims as they are received, which requires a certain amount of cash flow. So, if the claims are large or the plan is experiencing higher than expected utilization, the employer is counting on Stop Loss insurance to protect the company’s bottom line. But getting claims paid efficiently takes the effort of all involved – the carrier, the client and the administrator.

To help ensure claims are paid promptly, the right roadmap should be in hand from the start. The Stop Loss contract serves as the guide and sets the course. A solid Stop Loss contract will mirror the underlying plan document so that there are few questions about what is, or is not, covered. There also should be limited exclusions and limitations, helping to make claim review straight forward.

We have found, though, that there are a few essential items that are often overlooked during the claim submission process. These are the things that, if omitted, can slow down claims payment. And, they are required for the claim review. To help ensure the process is expedient, group administrators should remember to provide the following as part of the overall claim submission:

• Up-to-date premium payment
• A copy of the original enrollment card or a proof of eligibility screen print
• Supporting documentation for Continuation of Coverage (FMLA, LOA, COBRA)
• Coordination of Benefits (COB) information
• The Summary Plan Description (SPD)

These are just a few of the types of documents and data needed to process claims. They may sound obvious. However, you would be surprised how many times claims are submitted without this information, delaying the entire process. When you consider the impact on the cash flow of the group, this delay can have the same effect as denying the claim. Clients can find complete details of what is needed for claim submission in our Claim Submission Checklist. Be sure to review the details to determine if all the necessary information has been gathered.

At HM, we know that self-funded employers want to have confidence in the Stop Loss protection they have selected so that they can focus on their business goals. One way a carrier can deliver this confidence is by paying claims quickly and accurately. Doing so is more important than ever as claim frequency and severity continue to escalate, and as the industry faces this reality, we have to take the turns in the road together to arrive at our intended destination.