— Service
Claims & Utilization Review
Understand what is actually driving your costs. Most employers see the total — we show you the breakdown. High-cost claimants, network leakage, utilization anomalies, and the cost drivers your broker likely isn’t surfacing.
Sample Claims Breakdown
— The Hidden Problem
Most Employers Don't Have a
Pricing Problem. They Have
an Unseen Claims Problem.
Your broker shows you the renewal number. We show you why that number is what it is. Until you understand what’s driving claims at the category, provider, and member level, every renewal conversation is a negotiation without leverage.
The employers who save money aren’t the ones who switch carriers most often. They’re the ones who understand their data — and make decisions from it.
2–5 Large Claimants
Can drive 30–50% of total plan cost
GLP-1 & Specialty Drugs
Fastest-growing cost category at +22% YoY
Stop-Loss Laser Risk
Unmanaged claimants trigger costly lasers at renewal
Hidden Utilization Patterns
— Deep Dive
What We Analyze
We go beyond the summary your carrier provides. Here’s what a full claims and utilization review covers.
01
Large Claimant Identification
Identify the 2–5 individuals responsible for a disproportionate share of total plan cost. Understand clinical trajectories and stop-loss implications.
02
Network Utilization Analysis
Measure in-network vs. out-of-network utilization. Quantify leakage and identify provider steering opportunities that reduce cost without limiting access.
03
Cost-Per-Member Benchmarking
Compare your PMPM costs across medical, Rx, inpatient, outpatient, and ER categories against peer organizations in your industry and size range.
04
ER vs. Urgent Care Patterns
Identify members using the ER for non-emergency care — a major cost driver that can be addressed through plan design and member education.
05
Chronic Condition Prevalence
Map the chronic conditions in your population — diabetes, MSK, cardiac, behavioral health — and assess whether care management programs are effective.
06
Trend Analysis & Forecasting
Understand where costs are heading, not just where they’ve been. We project 12–36 month trends to inform proactive strategy, not reactive renewals.
—PROCESS
How the Review Works
A structured process designed to deliver actionable insight — not a 200-page report no one reads.
01
Data Collection
We request claims, eligibility, and plan data from your carriers — typically 24 months of history.
02
Analytics & Segmentation
We break costs into categories, flag outliers, and benchmark against peers at each level.
03
Findings & Recommendations
We present clear findings with specific, actionable opportunities ranked by potential impact.
— What You Get
Expected Outcomes
not just a broker who shows up at renewal time.
Full
Claims visibility by category
Top 5
Cost drivers identified
Peer
Benchmarking insights
Actionable
Prioritized opportunities
— Related Services
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Want to See What's Actually
Driving Your Healthcare Costs?
Start with a 15-minute conversation — no obligation.