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medical cost

Are High Dollar Medical Claims Out of Your Control?


If you stay in the employee benefit administration field long enough you are likely to encounter the half- to one-million dollar claim. The claim may be for a baby born prematurely, a cancer patient or hemophiliac. These claims may be for your employees or their dependents. The claimant may be a short- or long-term employee. And the claim may hugely impact your health plan cost going forward. Unfortunately, it may also impact how management views your performance.

It seems farfetched that top management would blame you for high dollar claims incurred by others. But it can happen… Despite privacy laws, management may feel that knowing your population’s health status is a central part of your job. And so is providing them with a heads up on potential high dollars claims, and having a strategy to address them. But is it your fault when the firm is hit by high dollar claims?

Are Unexpected High Dollar Medical Claims Your Fault?

Maybe. Consider this cautionary, true story.

Begin Story. A firm hired a full-time receptionist to work in one of their sales offices. She enrolled in the firm’s health plan as soon as she was eligible, the first of the month following 30 days of employment. After approximately 90 days of employment she received a formal performance evaluation. Her performance was not good. She was often late to work and took longer lunch breaks than allowed. In addition, her work product was not good. She made a lot of mistakes. Her manager terminated her employment after just six months and she immediately applied for COBRA family coverage. Continue Reading...