SLG Benefits and Insurance, LLC has developed a stop loss pricing model to recognize and reward Business Partners who actively report Claimant information based on the criteria described below.  We cannot stress enough the importance of early notification based on the proven cost management techniques employed by many top firms today.  Cost controls have become even more important in recent years as employers have elected to take on more risk to stem inflationary pressures on stop loss rates.  SLG Benefits established their Risk Management Department to facilitate the delivery of innovative cost containment techniques to produce real savings to the client both above and below the specific deductible selected.  We believe these efforts will ultimately result in longer-term stability in the employer’s stop loss pricing.

Business Partners that provide consistent reporting based on the criteria outlined below will receive underwriting credits in their stop loss pricing to acknowledge the risk management benefit they provide to their clients and ultimately the stop loss carrier.
 

Reporting Guidelines

TPA’s may use our notification filing forms or can choose to use their own notification forms if similar information is included.  We will also accept system generated reports provided they include important information as outlined below: 

• Group Name
• Policy Effective Date
• Employee name and social security number
• Claimant name, Date of Birth, Relationship to Employee, Diagnosis, and Claims paid to date

 We ask our Business Partners to report information that becomes known to them on all SLG Benefits groups within 48 hours or as soon as reasonably possible.  The reporting criteria we require are as follows:  

• Claimants who have reached 50% of the group’s specific deductible
• Claimants who have a PCL diagnosis(we recognize there is not a uniform trigger diagnosis list among stop loss providers and we are generally willing to work with a TPA’s standard reporting upon our review)
• Claimants who are incurring claims out-of-network
• Claimants who may require case management
• Claimants who are receiving specialty-type care, ie. Organ or Tissue Transplants, High cost and/or Infusion Drugs, Dialysis, Chemotherapy, Gastric Bypass

• Claimants who have requested approval for use of any experimental or non-FDA approved treatments, protocols, or drugs, or request the use of any off-label prescription drug therapies

• Claimants identified through the use of artificial intelligence software (if applicable) that have the potential to be catastrophic losses.
• Claimants with a Pre-certification request for a hospital stay greater than 7 days

We believe the optimum model for producing risk management opportunities is when the TPA, UR, and Case Management vendors work in conjunction with each other.  Our stop loss pricing credits put emphasis on the level of cooperation involved in the complete package.   Fragmented reporting may work for the larger mass production carriers, but we feel there is often much lost in the translation when you remove the human touch.  Our pricing credits are designed to incent this optimum level of cooperation and are only available after a thorough evaluation; 

 *Select Risk Management Credits may be implemented for Artificial Intelligence System Enhancements, Integrated Disease Management Programs, Wellness Plans, or unique value-added products and services that have been proven to favorably impact the risk profile of a group.  All Select Risk Management Credits require complete review and evaluation by SLG Benefits.