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This is what is driving your health insurance costs every year

Last week I taught you about two reports in the "Blue Insight - Monthly Financial Report" that I use to predict an employer's health insurance renewal far in advance of the actual renewal.

This week, I'm giving you an overview of the High Cost Claim report. Blue Cross Blue Shield of Illinois defines a high cost claim as over $50,000 in paid claims. If you don't have strategies to manage your high cost claims, you will continue to be frustrated and surprised by your health insurance renewals.

In this video, you'll learn some of the crucial information in these reports and how you can use this data to help build a strategy before your next health insurance renewal.

P.S. This is a friendly reminder to request your "Blue Insight - Monthly Financial Report" if your health insurance plan is with Blue Cross Blue Shield of Illinois.

Hey everybody, it's Mike Krupa and I am on a mission to teach Illinois employers just like you, how to better manage your health insurance plans. And over the last couple weeks we have been talking about the Blue Insight monthly financial report that Blue Cross Blue Shield of Illinois clients have access to. As long as you have 50 or more employees on your health insurance plan. Hopefully by now you've requested that data, you haven't and you're starting to analyze it. And these videos are meant to help show you some things to look out for. Last week we talked about the enrollment overview and the medical pharmacy lost ratio. And this week we are talking about high cost claimants. And high cost claimants are so important because 20%of the people in your plan are driving 80% of the costs. And if you're not doing anything to help manage that, you will continue to be surprised and frustrated by your renewals. So let's talk about what kind of useful information is actually in this report and what, what types of things I'm looking for. So first, you're always gonna wanna go over here to the right. This says paid. This is your total paid claims and what it represents. All these high cost claimants are gonna be everything over $50,000. That's how Blue Cross Blue Shield defines a high cost claimant. So this is ranging from $58,000 on the bottom, all the way up to this client had a $1.4 million claim. Alright, so you want to know how much it actually is. You wanna know if that person, that member, each one of these lines represents a different member. You want understand that that person is still currently enrolled within the health plan. This is just a yes or a no right here. This is super important. If you're a fully insured employer and you're considering self-funding, knowing this piece of information right here could be the difference of you getting a self-funded quote and not getting a self-funded quote. So this is pretty important here. I would definitely make sure you're looking at that. It is also important to understand the relationship. Is this a spouse? Is this a subscriber? Is this a child dependent? How old are they? Are they male? Are they female? And what was the actual category? Perinatal category for a $1.4 million claim for probably looks like a newborn. What's important here? Well, you know, maybe this is a, a little bit of information to tell me. Maybe this is a one and done type of claim. Maybe we reach back out to Blue Cross Blue Shield and just ask what the status is on this claim. Should we expect it again for the next year? Why is that important? Well, if you're fully insured, it's gonna impact your renewal. If you're self-funded, it's gonna impact your claims. But it's also important to understand the relationship here. Cause look, there's things you can do within your health plan to control this. It is very common that on this page there are a lot of spouses on the high cost claimant. Spouses typically cost more than employees dobe cause they take the coverage because they need it. So we often see spouses on here. But a strategy that some employers have implemented is something called either a spousal surcharge or a spousal carve out. And what this does is if that spouse has access to other coverage, they gotta take it. And if they don't, they either get charged extra to take this employer's plan or they're not covered at all. So knowing that might be enough information to implement something like that, obviously it's important to understand what these categories are, again, to determine if it's gonna be an ongoing claim or not, or maybe it's something that we can control a little bit more. And then lastly, what you can see here is they got it broken out by inpatient spend, outpatient professional or physician and pharmacy spend. And while I will look at all four categories,I am typically gonna focus on this pharmacy one, uh, because pharmacy is driving a lot of employers health spend right now. And what you see right off the bat here, 56,000 of the 58,000 in claims right there for that one individual was for pharmacy. And so I wanna dig into that a little bit deeper as well. And we are gonna do that in a future episode. Next episode we're gonna talk about some of the leading diagnostic categories within your health plan, why it's important to understand what those things are. And then we're gonna dig a little bit deeper in the following episode into pharmacy and specifically some of the things that are going on with this claim. I hope you enjoyed today's episode and I look forward to teaching you a little bit more next week. Thanks.

About the Author

Mike Kroupa, Self-Funding Insurance Expert

I grew up in a house that was constantly under construction and the experience helped me uncover one of my passions, remodeling. After running a successful remodeling business with my brother during college, I decided I wanted to keep this as a hobby. Instead, I took my advisor’s recommendation and started down the actuarial path, which ultimately led me to insurance.
Since then, I have focused my career teaching employers how to better manage their health insurance plans. I found myself frustrated year after year of doing the same thing because it didn’t feel like I was making an impact. Healthcare costs were continuing to increase, and it felt like the only options employers were left with was increasing deductibles, increasing contributions, and switching carriers.

There was a turning point for me in 2020 as I found Health Rosetta, an ecosystem for scaling adoption of practical fixes to our health care system. As my clients started adopting these fixes, I found myself getting passionate about what I was doing for the first time. Then I realized my hobby of remodeling was driving the passion because I was remodeling health plans. Even better, I was having an impact because patients (employees, spouses and children) were getting the best care they ever have and saving a lot of money in the process.

Get in contact with Mike: 

Phone: 630.738.1835     Email: mkroupa@gocgo.com     LinkedIn: Mike Kroupa

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