EXECUTIVE SUMMARY
Self-insured corporate health plans and stop-loss carrier policies frequently suffer from unverified claims repricing, high laser thresholds, and hidden administrative fees, driving up healthcare costs by 10% to 20%. Forensic claims auditing restores plan equity.
Self-insured health plans pay claims from company funds, with a TPA (third-party administrator) repricing each claim against a fee schedule. Repricing errors — incorrect allowed amounts, duplicate payments, or service-line mismatches — shift cost directly to the employer.
On top of claims, the plan carries administrative fees and stop-loss premiums. These include hidden per-claim fees, high laser thresholds on expensive claimants, and stop-loss provisions that are not benchmarked. Together, repricing discrepancies and opaque fees inflate total healthcare cost.
Controlling healthcare plan expenditure requires a forensic audit of both claims and the stop-loss structure. The protocol verifies repricing, challenges laser thresholds, and benchmarks administrative fees to restore plan equity.
Verify every claim's allowed amount against the negotiated fee schedule to catch overpayments and duplicate payment lines.
Review stop-loss lasers on specific claimants and negotiate thresholds down to actuarially defensible levels.
Break out TPA, per-claim, and stop-loss fees and benchmark them against market rates to remove hidden charges.
Institutionalize regular forensic claims review to stop repricing drift and fee growth before they compound.
A health plan and stop-loss audit verifies claims repricing, challenges high laser thresholds, and benchmarks administrative fees — lowering healthcare cost without changing coverage. The first step is a confidential advisory conversation.