Do you need our claims data too?
If your group is above your state’s small-group cutoff, fifty in Michigan, then yes, and so are your last three renewals. Carriers ask for both every time at that size. Below the cutoff your rates come off a filed community-rated table and claims are not part of the calculation at all.
Above the small-group cutoff, yes. Below it, usually not.
Claims are what a carrier prices once your group is rated on its own experience, so a review without them can compare rates but cannot judge them. Below the small-group cutoff, rates come from a filed table and claims do not change them.
If your carrier will not release claims to you, a one-page authorization lets it release your own information to us.
How claims are used.
To Explain the Increase
Whether a handful of cases or broad utilization drove it, which decides the levers worth pulling.
To Brief the Carrier
Only with your say-so, and only after we tell you what will be shared.
To Test Alternatives
Quotes from other carriers are only as good as the claims picture they are based on.
What Claims Data Tells Us.
Above the small-group cutoff, a carrier prices your group partly on its own experience. Claims data shows what drove cost, whether a few large claims or broad utilization, and whether pharmacy spending is rising.
The data also tells us how much of an increase is likely to stay and how much may be a one-time event. That affects whether to negotiate, change plan design or consider a different funding arrangement.
Claims reports come from the carrier in de-identified form, and privacy rules apply.
Questions about claims.
How is claims data protected?
It is limited to the team working on your review, handled as protected health information and never shared without your approval.
What if I do not have a claims report?
Ask your carrier or broker. If that is not possible, we can start without it and say what the read cannot cover.
What counts as large claims?
Whatever your carrier reports above its threshold. We read them for the condition and whether treatment is ongoing.
How far back do you need?
Typically twelve to twenty-four months, plus prior renewals.
Can we get it ourselves?
Your carrier or broker can usually request it for you.
Do small groups need claims data?
Under the small-group cutoff, rates come from filed schedules, so claims are generally not part of the price.
General information, not legal advice. Plan-specific questions belong with your counsel, and we will bring them in.
Where to go from here.
Back to send us your renewal →
Document six: claims experience →
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