Managing High-Cost Claims: Best Practices from TPAs
Proven Strategies to Protect Plans and Members
High-cost claims can challenge even the most carefully managed self-funded plans. Specialty medications, complex hospital stays, and chronic conditions can drive costs up quickly and unpredictably.
That’s why brokers and employers rely on TPAs with proven processes for managing these claims effectively. At ACS Benefit Services, that means combining data-driven insight with a personalized approach to care coordination. Every claim is reviewed not just for cost, but for impact to ensure plans remain stable and members receive the attention they deserve.
Early Identification Makes All the Difference
The sooner a potential high-cost claim is recognized, the easier it is to control. TPAs use real-time data and predictive analytics to flag early warning signs like recurring hospitalizations, specialty drug use, or gaps in care.
Once identified, ACS case managers engage immediately by:
- Coordinating with physicians and specialists to guide treatment
- Reviewing care options for effectiveness and cost
- Helping members understand their plan and next steps
This proactive approach often prevents complications before they happen. In one recent case, ACS identified a member’s rising pharmacy costs early, working with the PBM to adjust therapy and implement a manufacturer assistance program. The result: thousands in savings for the plan and uninterrupted access to care for the member.
Collaboration Drives Better Outcomes
Managing high-cost claims requires teamwork. TPAs like ACS bring together providers, PBMs, and clinical experts to create a single, connected approach to care. This coordination ensures the member’s health and the plan’s financial health stay aligned.
Key areas of focus include:
- Specialty drug management: Partnering with PBMs to evaluate utilization and explore lower-cost alternatives when appropriate.
- Provider communication: Maintaining open dialogue with hospitals and specialists to confirm treatment necessity and avoid duplicate services.
- Member engagement: Offering support, education, and case management to encourage adherence and recovery.
In the PBM case study, ACS’s collaboration across multiple stakeholders resulted in a 20% reduction in specialty pharmacy spend. Proof that connection and communication drive meaningful results.
Balancing Care and Cost Creates Sustainable Plans
Every high-cost claim represents both a financial decision and a human story. The goal isn’t to cut corners. It’s to deliver quality care in the most efficient way possible.
ACS focuses on:
- Promoting evidence-based treatments
- Reducing unnecessary services and readmissions
- Supporting members through personalized case management
This balance of compassion and control creates lasting value. Employers gain predictable plan performance, members receive better care experiences, and brokers can feel confident knowing their clients are supported by a partner they can depend on.
Learn how ACS turns strategy into measurable savings in its latest pharmacy management success story: