Bill Frack
Co-founder & Chief Development Officer, Wellnecity
Shortly after publishing our last newsletter, Eliminating Costly Health Plan Leakages: Real Losses Recovered, I was alerted to another significant underpayment. In 2024, our client experienced an under-reimbursement of $1.5M from their stop-loss provider — a substantial impact for a plan covering approximately 1,800 employees.
Why did this occur? Poor carrier reporting — across multiple members, for multiple different reasons. You might ask: "What is NOT in your wallet?"
Schedule of Underpayments
Q1 2024
Carrier omitted Member #1 from their Specific Stop-Loss (SSL) report, resulting in mitigated costs of $1.3M.
Carrier mis-identified Member #9, missing $6K in spend.
Wellnecity followed up with the carrier, presenting details to correct both issues — which the carrier confirmed and corrected.
Q2 2024
Carrier did not account for pharmacy spend for Member #2 and Member #11 in their SSL report.
Wellnecity followed up with the carrier to have pharmacy spend included in the eligible stop-loss spend.
Q4 2024
Carrier did not account for the following in their SSL report:
- — Member #13 — $172K in missed medical spend
- — Member #15 — $155K in missed spend across medical and pharmacy
- — Member #16 — $70K in pharmacy spend not accounted for
Wellnecity coordinated with the carrier to include all missed spend by presenting detailed data and verifying reports — then worked directly to correct the mistakes and reverse the underpayment.
