5 Ways to Mitigate High Cost Claims

Posted On: October 3, 2017 | By: Abigail Cutler

While America waits for the Trump administration to deliver the change to healthcare that in part elected him, the reality is that high costs are here, and immediate action is necessary. According to The Kiplinger Letter, 10% of patients currently account for 65% of health costs. While we wait for our political leaders to act on lowering healthcare costs, here are 5 things you can do to mitigate high cost claims.

Partial Self-Funding 

Think of it this way—when paying an insurer, you’re not only paying for claims incurred, but the administration, overhead, and profit of the insurer. When employers partially self-fund their healthcare plan, they pay for claims and small administration fees, cutting out the cost of the middleman. Even with the addition of stop-loss insurance, costs are dramatically reduced. The icing on the cake? Increased transparency, plan reporting, and customization.

Reference-Based Pricing

One of the many hidden gems of partial self-funding, reference based pricing, allows you to set reimbursement rates for drugs and other medical costs based on accepted standards, such as Medicare reimbursement rates. In our experience, companies conservatively save $150,000 for every 100 eligible employees in by adopting this technique.


While waiting for the political future of our healthcare system, the future of our physician-patient experience has already arrived. Telemedicine allows patients to video-conference with a doctor in real time, receive a diagnosis and prescription, and in many cases, have that prescription sent to a preferred pharmacist. As a cost comparison, an October visit to my doctor showed my insurer was billed $469 after my $50 copay. Over the weekend, I used HealthiestYou telemedicine services, saw a doctor immediately, and my insurer and I were billed nothing (I pay a little over $10 a month for the service).

Large Case Management Programs

While a small percentage of the population drives the majority of claims, employers usually do not have anyone coordinating claims. A large case manager can coordinate care to reduce redundant or unnecessary testing, ensure proper pharmaceutical utilization, and oversee that paid claims are justifiable.

Working Spouse Provisions

If an employer is currently paying for an employee’s spouse who has coverage available through his/her own employer, the employer can elect a spousal carveout or surcharge to remove working spouses from the healthcare plan. In short, plan enrollment decreases and claims costs drop.