When it comes to managing expectations for Aggregate stop loss claims, preparation is key. While many in the stop loss industry are well-versed in filing individual Specific claim reimbursement requests, Aggregate claims require a bit more planning. Here are three important things to keep in mind:
1. Set reasonable expectations up front
It’s crucial to wait until the stop loss carrier confirms a reimbursement has been approved before setting expectations with your client. Although the “summary paid claims report” prepared at the end of the policy period might suggest that an Aggregate claim reimbursement is forthcoming, the stop loss carrier’s audit report might indicate otherwise. This may be due to ineligible items like administration fees and other non-covered expenses on the summary report. Avoiding premature assumptions can help you manage expectations more effectively.
2. Recognize significant industry trends: GLP-1s
One notable trend identified during Aggregate claim audits is the expanded use of GLP-1 agonist drugs, such as Wegovy®, Ozempic® and Mounjaro®, beyond the indications approved by the Food and Drug Administration or outside the coverage provisions outlined in the employer’s plan document. Being proactive is essential to ensure that the pharmacy benefit manager (PBM) is dispensing GLP-1 drugs in alignment with the plan’s “medically necessary,” “weight management” and “step therapy” provisions. With this in mind, the self-funded plan must confirm who is responsible for communicating coverage expectations clearly with the PBM. It’s highly recommended to review plan document provisions in advance to ensure all parties—the employer, covered participants, the third-party administrator (TPA) and the PBM—understand how GLP-1 drugs are covered under the plan.
3. Explain why rebates are generally not considered “covered expenses”
A common issue during Aggregate claim audits is that PBM rebates are usually deducted from the reimbursement. Rebates are generally not defined as “covered expenses” in the employer’s plan document. Rather, rebates represent credits the self-funded plan receives from the PBM after the policy period ends. This is why rebates are usually deducted from the Aggregate claim reimbursement request and are categorized similarly to refunds or subrogation recoveries. Many customers question why rebates are deducted on Aggregate claims but not Specific stop loss claims. The simple reason is that the rebate percentage of the drug price is not disclosed when the prescription is dispensed, making it impossible to identify the rebate amount up front. Awareness of this can help manage expectations and avoid further confusion at time of claim.
By following these three steps, stop loss policyholders, brokers and TPA partners can more effectively navigate the filing process to obtain Aggregate claim reimbursements.
