Expert Eyes, Reduced Risk with Clinical Reviews

In today's volatile health care landscape, a single catastrophic claim can place a significant financial burden on a self-funded employer's resources. That’s why Stop Loss insurance is more essential than ever in helping to shield these companies against the impact of unanticipated, exceptionally high-cost medical claims. 

But even with Stop Loss coverage providing financial protection in these instances, the long-term health of a self-funded plan is best preserved by a Stop Loss carrier that works to effectively manage risk using the insights gained through expertly executed clinical reviews. This approach helps to reduce exposure and keep premiums manageable in relation to outcomes. It all starts with monitoring and mitigating high-cost claims before they grow to catastrophic levels. 

At HM Insurance Group, we have a team of experienced nurses and pharmacists who conduct clinical claim reviews to unlock valuable information and transform the way our Stop Loss insurance is managed. Throughout the process, we focus on mitigating risk and proactively controlling costs where possible. 

What Is a Clinical Review?

In the world of Stop Loss, a clinical review is a comprehensive evaluation of medical claims data, patient records, and the proposed treatment plans for both current and prospective clients. The process provides a second set of expert eyes to review complex cases and help to ensure appropriate evidence-based, cost-effective care is in place. 

The Unique Expertise of Nurses and Pharmacists

Both nurses and pharmacists are vital in clinical reviews and can offer distinct perspectives and skill sets to identify and analyze high-cost claims. 

Nurses excel at understanding the patient's whole health experience, including the coordination of care across different providers. They analyze claims to better understand a patient’s medical journey and determine appropriate costs of care. For instance, pre-term infants often represent one of the biggest cost-drivers for clients. Nurses meticulously track claims associated with these infants – from their extended and expensive NICU stay through discharge and subsequent home care. This close oversight helps to ensure cost accuracy and enables better prediction of the impact of such cases on the book of business.

Pharmacists possess a deep knowledge of medications, drug interactions, dosing requirements, and cost-effective alternatives – information that significantly aids in claim reviews. For example, a pharmacist might recognize a cost challenge associated with site of care and can propose that a certain specialty drug that’s currently being administered in a hospital outpatient setting might, instead, be administered at home. This recommendation provides an option that could significantly reduce the cost of the medication without compromising the patient’s health. 

Benefits of Clinical Reviews

Clinical reviews provide a multitude of benefits, making them an indispensable tool for managing risk in the Stop Loss industry. Such benefits can include:

Improved Risk Assessment – Clinical reviews provide a granular and accurate understanding of the risks associated with Specific claims. Expert reviewers can identify pre-existing conditions, comorbidities, and other risk factors that may impact claim costs. This allows the Stop Loss carrier to make more informed underwriting decisions and price policies accordingly for optimal client benefit.
Proactive Cost Management – By identifying opportunities to optimize care and prevent unnecessary expenses, clinical reviews help to get ahead of the curve on managing costs.
Enhanced Claims Management – Clinical reviews work to improve the efficiency and accuracy of claims processing. Fraudulent or abusive billing practices may be identified, helping to ensure that claims are for medically necessary care and appropriately coded.
Data-Driven Insights for Better Decision-Making – Clinical reviews provide a wealth of data and insights that can be used to improve Stop Loss underwriting, pricing, and risk management strategies. The aggregated data can reveal trends in high-cost claims and identify areas for improvement in health care delivery.

Knowledge is power in the complex world of health care. Clinical reviews can identify potential risks before they become financial misfortunes, helping to ensure a healthier bottom line and better outcomes for everyone involved. By leveraging the unique expertise of nurses and pharmacists, HM Insurance Group works to aid self-funded employers in proactively managing risk, helping to control costs and improving the overall quality of care they achieve with their plans.