Understanding the Stop Loss Claim Process
In the event of larger than planned or catastrophic claims, self-funded health plans rely on their stop loss insurance policy to help protect their cash flow and maintain financial stability. But what does this process look like for the employer?
At American Fidelity, our dedicated team of experienced professionals help ensure these claims are handled fairly, accurately, and quickly.
Initial Claim Review
When a claim is submitted, our claims analysts complete a comprehensive review of the policyholder’s plan in conjunction with the excess policy to determine eligibility and applicable coverage. A financial audit of all charges is then completed to ensure all payments were made in accordance with the plan and any discounts, deductibles, etc. were applied appropriately.
Our analysts look for cost-containment opportunities that are mutually beneficial to the plan and American Fidelity. Where appropriate, large charges are referred to specialized vendors to screen for billing errors and/or negotiate for further savings beyond the Preferred Provider Organization (PPO) discounts that may already be in place. Additionally, our analysts work to identify subrogation opportunities where there may be potential to recover from a responsible third party.
Working closely with the claims team, our Clinical Risk Management colleagues identify developing high-cost claims and recommend (and often facilitate) cost-containment strategies. This may include the placement of transplant contracts and vendor referrals to secure favorable pricing on high-cost treatments.
American Fidelity recognizes speedy payment is paramount to minimize the disruption of the plan’s cash flow. American Fidelity’s stop loss policies provide flexible reimbursement options including Specific Advance reimbursement on claims exceeding $1,000.
We Can Help
Our dedicated stop loss team brings an extensive knowledge base to process stop loss claims efficiently. This helps the employer to recognize the benefits of a self-funded plan.