Industry Insights

You can probably imagine that working with more than 100 third party administrators (TPAs) means that HM Insurance Group (HM) receives tens of thousands of claim detail files every year. It’s a lot of data to manage. Files come into a secure, designated Stop Loss claims email box or via an FTP site. They are then saved to a corporate drive so our Claims team can format the TPAs’ Excel files into a format acceptable for loading into our claims system. The entire process takes a lot of manual work.  

We’ve all heard about gout. It’s that sharp, hot pain and swelling that most commonly afflicts the big toe. One of the world’s oldest recognized diseases, gout was first identified by the Egyptians in 2640 BC and has been viewed as a lifestyle disease of the rich and affluent, primarily because of its connection to certain more expensive dietary habits. This “disease of kings” has been problematic for ages, with little change in the treatment options that first were identified thousands of years back – until a few years ago.

As a pharmacist, in the past 20-plus years, I’ve owned my own pharmacy, worked for a PBM (pharmacy benefit manager), served as a consultant to health plans and more. Now, I find myself in the operations department of a Stop Loss carrier. As pharmaceutical costs continue to rise and new drugs debut with million-dollar price-tags, the market is seeing greater catastrophic claims expenses – and I’m working to share my industry knowledge and understanding of pharmaceutical costs and use across the client population.

I love solving problems. That’s the best part of my job. Lucky for me, we’re in a thought-provoking industry – one that’s become even more challenging with the growth of high-dollar claims. As a reinsurer, paying those claims is the most important thing we do. The challenge lies in creating the right solution for each client, appropriately pricing business to ensure obligations can be fulfilled and finding ways to help contain claim costs for everyone involved.

Adding a reference-based pricing component to an employer’s health plan brings an element of clarity to benefit costs by determining, from the start, what is to be paid for medical services and procedures. It’s no surprise that reference-based pricing is a hot topic in the market today, especially when claims exceeding $1 million are more and more common. Reference-based pricing is part of a greater movement toward transparency, helping to establish some type of a standard for what is paid for medical care.