Demo Data · jmum corp (420 employees)
Claims Overview — 2025
Annual summary for jmum corp's self-insured health plan. All figures are aggregate; no individual-level data is displayed.
Total Paid Claims
$4.82M
↑ 11.4% vs prior year
PEPY (Per Employee/Year)
$11,476
↑ 8.9% vs $10,538
Total Members
842
420 employees + 422 dependents
Catastrophic Claims
6
↑ 2 vs prior year · $1.2M total
Claim Count
14,390
↑ 6.2% vs prior year
Stop-Loss Attachment
$150K
3 claims exceeded · $410K recovered
Monthly Claims Trend
Total paid claims by month (2023–2025)
Spend by Claim Type
Medical/Outpatient
34%
Inpatient
28%
Pharmacy
22%
Mental Health
10%
Other
6%
Key Insights
6 catastrophic claimants account for 24.9% of total spend ($1.2M). Monitor actively.
PEPY up 8.9% vs 5.2% industry average — trend above market.
Stop-loss triggered on 3 claims; $410K recovered this year.
Pharmacy spend growing +17% — specialty drugs driving increase.
Member Distribution
Avg Age
38.4
Employees
Female
54%
of members
Plan Enrollment
HDHP/HSA
38%
PPO
47%
HMO
15%
Utilization Patterns
Understanding what services members are using and how diagnoses are trending year over year.
ER Visits / 1000
248
↑ 12% · Benchmark: 190
Inpatient Admits / 1000
74
Benchmark: 70–80
Avg Length of Stay
3.8d
↓ 0.3d vs prior year
Telehealth Visits / 1000
112
↑ 31% — growing
Top 10 Diagnosis Categories
By paid amount — 2025 vs 2024
Claim Type Trend
High-Cost Claimant Analysis
At your group size, 1–2 catastrophic cases can shift PEPY by 10%+. Stop-loss is critical.
| Tier | Members | % of Members | Total Spend | % of Spend |
|---|---|---|---|---|
| $100K+ | 6 | 0.7% | $1,200,000 | 24.9% |
| $50K–$100K | 14 | 1.7% | $980,000 | 20.3% |
| $25K–$50K | 32 | 3.8% | $1,120,000 | 23.2% |
| Under $25K | 790 | 93.8% | $1,520,000 | 31.5% |
Benchmark Comparison
ER Visits / 1,000
248
vs 190
+31% ↑
IP Admits / 1,000
74
vs 75
On par
Avg LOS (days)
3.8
vs 4.1
Better
PEPY
$11,476
vs $10,200
+12.5% ↑
Generic Rx Rate
72%
vs 80%
Below ↓
Telehealth Use
112/1K
vs 95/1K
Above ✓
Cost & Plan Design
Analyzing network utilization, benefit structure, and appropriateness of care settings.
In-Network Rate
87%
Benchmark: 88–92%
OON Spend
$627K
↑ 18% vs prior year
Avg Deductible Met
$1,840
PPO: $2,000 deductible
Employer Cost Share
76%
Industry avg: 73–78%
In-Network vs. Out-of-Network Spend
OON spend rising. Top OON categories: Anesthesiology (29%), Behavioral Health (22%), Emergency Physicians (18%). Consider network adequacy review.
Care Setting Appropriateness
248 ER visits/1,000 vs benchmark 190. Est. $180K in avoidable ER costs if redirected to urgent care/telehealth.
Plan Design Summary & Competitiveness
| Design Element | PPO | HDHP/HSA | HMO | Industry Median | Assessment |
|---|---|---|---|---|---|
| Employee-only premium/mo | $180 | $95 | $145 | $155 | Competitive |
| Annual deductible | $2,000 | $1,600 | $500 | $1,800 | Market |
| OOP Maximum | $6,000 | $5,500 | $4,000 | $6,500 | Favorable |
| PCP copay | $25 | Post-ded | $20 | $25 | At market |
| Specialist copay | $50 | Post-ded | $35 | $45 | Slightly high |
| ER copay | $300 | Post-ded | $250 | $350 | Below avg |
| Employer HSA contribution | N/A | $750 | N/A | $600 | Above avg |
Pharmacy Spend
Analyzing drug utilization, generic adoption, specialty pharmacy trends, and site-of-care optimization.
Total Rx Spend
$1.06M
↑ 17.1% vs prior year
Specialty Rx Spend
$488K
↑ 28% · 46% of total Rx
Generic Fill Rate
72%
Benchmark: 80% · Gap cost: ~$95K
Rx Claims
4,820
↑ 9.2% vs prior year
Top 10 Drugs by Cost
All figures are paid amounts
Specialty vs. Traditional Rx Trend
Top 10 Drugs by Utilization & Cost
| Drug | Class | Claims | Paid | Per Claim | Generic Available? | Opportunity |
|---|---|---|---|---|---|---|
| Humira (adalimumab) | Biologic / RA | 84 | $142,000 | $1,690 | Biosimilar avail. | High – switch biosimilar |
| Ozempic (semaglutide) | GLP-1 / Diabetes | 120 | $118,000 | $983 | No generic | Prior auth / step therapy |
| Keytruda (pembrolizumab) | Oncology | 18 | $98,000 | $5,444 | No generic | Site-of-care review |
| Eliquis (apixaban) | Anticoagulant | 196 | $84,000 | $429 | Generic 2026 | Monitor |
| Dupixent (dupilumab) | Biologic / Derma | 36 | $72,000 | $2,000 | No generic | Prior auth |
| Trulicity (dulaglutide) | GLP-1 / Diabetes | 88 | $58,000 | $659 | No generic | Formulary mgmt |
| Lisinopril | ACE / Hypertension | 412 | $14,000 | $34 | Generic ✓ | Optimal |
| Atorvastatin | Statin / Cholesterol | 384 | $12,000 | $31 | Generic ✓ | Optimal |
| Metformin | Oral / Diabetes | 328 | $8,200 | $25 | Generic ✓ | Optimal |
| Sertraline (Zoloft) | SSRI / Mental Health | 276 | $7,400 | $27 | Generic ✓ | Optimal |
Generic & Biosimilar Opportunities
Generic fill rate is 72% vs 80% benchmark. Closing this gap could save ~$95K annually.
Humira biosimilars now available (Hadlima, Hyrimoz). Switching could save $50–80K/year.
Site-of-care for infusions: Moving from hospital outpatient to home infusion or office can cut costs 30–60%.
Specialty Pharmacy Program
Specialty through SPP
68%
Goal: 90%+
Gap
Prior auth compliance
88%
Good
Adherence (PDC 80%+)
71%
Benchmark: 75%
Below
Copay accumulator active
Yes
✓ Active
Chronic Condition Management
Prevalence, engagement in disease management programs, and downstream cost signals.
Members w/ Chronic Dx
38%
319 of 842 members
DM Program Enrollment
52%
Of eligible diabetics enrolled
Preventable Admits
14
↑ 3 vs prior year · $210K
Avg PMPM (Chronic)
$1,840
3.2× non-chronic
Chronic Condition Prevalence
Disease Management Engagement
| Condition | Members | In DM Program | Engagement | Trend |
|---|---|---|---|---|
| Diabetes (Type 2) | 68 | 35 | 52% | ↑ Improving |
| Hypertension | 112 | 44 | 39% | ↓ Low |
| Musculoskeletal / MSK | 94 | 22 | 23% | ↓ Very low |
| Mental Health | 78 | 31 | 40% | ↑ Growing |
| Asthma / COPD | 42 | 24 | 57% | Stable |
| Cancer (active) | 9 | 9 | 100% | Case mgmt |
MSK engagement at 23%. Back/spine conditions are #2 spend driver. Consider adding a dedicated MSK navigation point solution.
Downstream Cost Signals (Gaps in Care)
14 preventable inpatient admissions linked to chronic conditions — $210K avoidable spend.
22% of diabetic members had no HbA1c test in the past year — care gap.
Hypertension adherence (PDC): 68% — below 80% target. Medication non-adherence costs $3K–$7K per patient/year downstream.
Preventive Care & Wellness
Utilization of ACA-mandated preventive services, screening rates, and wellness program effectiveness.
Annual Physical Rate
61%
Benchmark: 65–70%
Mammography Rate
58%
↓ Below HEDIS 72%
Colorectal Screen Rate
54%
↓ HEDIS target: 68%
Wellness Engagement
44%
↑ 6% vs prior year
Preventive Service Utilization
ACA-Mandated Preventive Services Gaps
| Service | Eligible | Utilized | Rate | vs Target |
|---|---|---|---|---|
| Annual physical / AWV | 420 | 256 | 61% | Moderate gap |
| Mammography (F, 40+) | 148 | 86 | 58% | Large gap |
| Colorectal screening (45+) | 182 | 98 | 54% | Large gap |
| Cervical cancer screen (F 21–65) | 196 | 134 | 68% | Near target |
| Flu vaccination | 842 | 462 | 55% | Below 70% |
| Diabetes screening (BMI 35+) | 94 | 46 | 49% | Low |
| Blood pressure screening | 420 | 368 | 88% | Good |
| Cholesterol / lipid panel | 284 | 188 | 66% | Near target |
Wellness Program Effectiveness
Engaged members
185
44% of eligible employees
Engaged members show 28% lower PMPM vs non-engaged ($890 vs $1,240).
Biometric screening rate
38%
↑ 4% vs prior year
Biometric screening below 50% target. Consider on-site clinic day or incentive increase.
Incentive redemption
62%
of $500 wellness benefit
38% of wellness budget unredeemed. Review program structure or communication strategy.
Mental Health & Behavioral Health
Mental health and substance use disorder claims, EAP utilization, and parity compliance indicators.
BH Claim Rate
9.3%
of members used BH benefits
Total BH Spend
$482K
↑ 22% vs prior year
EAP Utilization
6.8%
Benchmark: 5–8%
Avg Sessions / User
7.4
Benefit limit: 20 sessions
Mental Health Spend Trend
BH Diagnosis Breakdown
Anxiety disorders34%
Depression / MDD28%
Adjustment disorders14%
SUD / Substance Use12%
Other / Unspecified12%
Parity & Access Checklist
- ✅ Mental health/SUD parity compliance: BH cost-sharing mirrors medical benefits. No separate deductibles or lower visit limits. Annual parity analysis completed.
- ✅ EAP-to-care connection rate: 71% of EAP users successfully connected to ongoing care. (Benchmark: 60–70%)
- ⚠️ Network adequacy — BH: Average wait time for in-network therapist: 18 days. Target: under 10 days. Consider virtual therapy platform (Headspace, Spring Health, Lyra) to expand access.
- ⚠️ SUD treatment access: 12% of BH claims are SUD-related. Only 40% accessed residential or IOP treatment within 7 days of referral.
- ✅ No prior auth for initial outpatient BH sessions: First 6 sessions available without PA — reducing access friction.
- 💡 Opportunity: Anxiety and depression (62% of BH claims) are highly treatable with early intervention. Digital CBT tools can reduce severity and cost per episode.
Vendor & Carrier Performance
Evaluating TPA/carrier care management effectiveness, case management, UR, and stop-loss performance.
Stop-Loss Recovered
$410K
3 claims above $150K attachment
UR Denial Rate
3.2%
Industry avg: 2.5–4%
Case Mgmt Enrollment
78%
Of eligible high-risk members
Network Discount %
48.2%
Benchmark: 45–52%
TPA Performance Scorecard
| Metric | Actual | Contractual SLA | Status |
|---|---|---|---|
| Claims turnaround (avg days) | 14.2 | ≤ 15 days | ✓ Met |
| Claims accuracy rate | 98.6% | ≥ 98% | ✓ Met |
| Network discount % | 48.2% | ≥ 45% | ✓ Met |
| UR concurrent review rate | 81% | ≥ 85% | ⚠ Miss |
| Case mgmt outreach (high-risk) | 78% | ≥ 90% | ✗ Miss |
| Member satisfaction (CSAT) | 4.1/5 | ≥ 4.0 | ✓ Met |
| Subrogation recovery rate | 1.4% | ≥ 1% | ✓ Met |
| COB savings (coordination) | $38K | Best effort | Informational |
Stop-Loss Analysis
Stop-loss at $150K specific / $5.8M aggregate. This year's ratio: specific claims = 24.9% of total spend. Attachment point appears well-sized.
Given upward trend, consider modeling $125K attachment at renewal to improve predictability.
Large / Complex Case Management
Cases in active CM
22
High-risk / chronic
Catastrophic cases flagged
6 / 6
100% flagged within 5 days
CM enrollment rate (eligible)
78%
⚠ Below 90% SLA
Case management enrollment is below SLA (78% vs 90%). Escalate with TPA — missed CM on high-risk members represents significant downstream cost risk.
Renewal & Strategy
Projected renewal outlook, plan design levers, and strategic recommendations for the coming year.
+13–16%
Projected Trend
Actuarial renewal range estimate
$240K
Identified Savings Levers
If all opportunities captured
$5.3M
Projected 2026 Spend
Before interventions
Cost Savings Opportunity Waterfall
Peer Benchmarking (PEPY)
Strategic Recommendations
-
🔴
Biosimilar conversion (Humira → Hadlima/Hyrimoz): Implement formulary PA requiring biosimilar trial for new starts. Est. savings: $50–80K.
-
🔴
ER diversion program: Implement 24/7 nurse line + telehealth-first triage. At 248/1K ER rate vs 190 benchmark, addressable gap = ~$150–180K.
-
🟡
MSK point solution: Adding a digital MSK program (e.g., Hinge Health) targets #2 spend category. ROI typically 2:1 in 12–18 months.
-
🟡
Generic Rx incentive: Increase member cost-share differential between brand and generic. Closing gap from 72% → 80% generic fill rate saves ~$95K.
-
🟡
Virtual therapy platform: Replace/supplement EAP with dedicated mental health platform (Lyra, Spring Health). Addresses 18-day wait time and growing BH trend.
-
🟢
Stop-loss renegotiation: Given 3 claims above $150K, model $125K attachment at renewal. Also explore lasering if a known high-cost member is still enrolled.
-
🟢
TPA SLA enforcement: Case management enrollment at 78% vs 90% SLA. Issue formal cure letter and request credit/remediation per contract.
-
🟢
Preventive care gap campaign: Mammography (58%) and colorectal screening (54%) are below HEDIS targets — run targeted outreach. Zero-cost to members under ACA.
Alternative Funding Strategies to Explore
Level-funded plan: If moving away from fully-insured, level funding offers cost transparency + potential surplus refund with less risk than full self-funding.
Reference-based pricing: For high-volume, shoppable procedures (imaging, labs). Can reduce those charges by 20–40% vs. carrier contract rates.
Direct primary care (DPC): Add DPC layer to reduce PCP visit costs and improve chronic condition management. Works best alongside HDHP.