by Nathan Savage, Underwriter and April St. Cyr, Claims Manager
As we hear more and more people talking about stop-loss policies, the hot topic that keeps coming up seems to be lasers.
In its simplest form, a laser involves adjusting the stop-loss deductible for an individual who has a very high likelihood of exceeding the group’s regular individual specific deductible.
Lasers can present the group with additional liabilities – but as with any insurance, the coverage is for unknown risks, rather than known risks. There is also a cap that when hit, would start reimbursements. This allows a group to have a max cost, even on riskier members. (For example, we may have a laser of $250,000 for a cancer diagnosis but if the member’s claim goes over that amount, we still reimburse over the laser.)
Lasers can also be conditional, and are typically based on events such as transplants or chemotherapy. When this is the case, the covered member must meet the group’s specific deductible for anything that does not pertain to the condition set.
So when are lasers considered?
We start looking at members during the underwriting process. If there are obvious claimants who we predict will be over the group’s deductible, we make a note of it on our initial quotes.
Lasers are finalized when a group’s disclosure is signed and sent to us with supporting documents. The disclosure is an important tool that gives us an accurate and detailed picture of all known claimants or high-risk individuals. It’s also the last time that we look at the group to set lasers.
Click here to read more about the role disclosures play in the underwriting process.
Limiting exposure to all parties involved
When a notice is received on behalf of a high risk member, our Medical Management team reviews the notice using the following typical reporting:
– High claim reports
- – Pended reports
- – Pre-certification reports
- – Case management reports
Based on the findings in these reports, we further research costs using web-based tools that provide critical information (such as clinical and financial
analytics) and help with managing, reimbursing, and underwriting catastrophic claims.
Our team may also reach out to the TPA or case manager for any additional questions or information pertaining to the group in general, or the claim in particular.
And that’s not all.
ASG has established relationships with leading vendors who are willing to work with us, our TPA partners, and the employer group to secure deeper discounts for coverage of high-risk members.
Often, a medical bill review and audit company, or a medical cost containment and claims flow management organization, is able to negotiate with a provider and get sign-off on a rate that benefits all parties. Transplant networks for solid organ and bone marrow transplants offer excellent contracts to help mitigate the financial sting of complex care.
When Lasers Meet Claims
As we stated above, the laser is conditional and therefore specific to the covered individual. Following is a typical example.
Say Sue Smith’s policy includes a $150,000 conditional laser in the event of chemotherapy, and her employer group carries a $50,000 regular deductible.
If Sue undergoes a chemotherapy regimen and meets her laser of $150,000, our TPA partner would send in all required reporting for filing a claim as it would for anyone on the plan, regardless of a specific deductible. Our claims analyst would review and process the claim the same way as if there were no laser.
On the other hand, if Sue goes in for a knee replacement – which obviously is different than chemotherapy – and the knee replacement costs $70,000, we would simply reimburse the company the $20,000 difference over their deductible.
No matter the size of the policy or number of lasers included, what’s most important to an MGU like us is confirming that the claims:
- – Are paid according to the plan document
- – Meet all requirements of the stop-loss policy
At the end of the day, our goal is to write and stand by a policy that works for all parties involved.
We’re here to answer your questions about lasers. Contact us at any time!