Three engagements, with the numbers
Client names are withheld by agreement. Figures are as the clients reported them.
| Engagement | Situation | Result | Claudia’s role |
|---|---|---|---|
| From fully insured to self-fundedFinancial services, 3,000+ employees | Premiums rose 8 to 12% a year. HR had no claims visibility and no leverage at renewal. | $4M+annual savings by year two | Claims audit, stop-loss design, TPA and PBM selection, employee communication |
| Closing the book on aging claimsFinancial services, 500+ employees | Aging open claims were driving the experience modifier toward a $500,000 premium increase. | $500K+in workers’ comp reserves released | Claims inventory, closure planning, carrier stewardship, premium modeling |
| Eliminating spread pricingHealthcare-adjacent services, 1,200+ employees | Seven years with one PBM buried inside a carrier package. The employer had never seen a drug-level claims report. | 40%pharmacy cost reduction per member | Contract deconstruction, pass-through RFP, formulary review, member education |
From fully insured to self-funded
A major California financial institution had been fully insured for decades. The carrier was pricing for risk it could not see. The CFO had flagged benefits cost as one of the top three threats to operating margin, and the CHRO needed a fix that would not push turnover in a tight labor market.
Per member, per year
Specific stop-loss pays
$150,000
The plan pays
Whole plan, per year
80% of cost came from 12% of claimants. That concentration is what made self-funding viable.
What was done, in order
- Claims audit and modeling A three-year retrospective showed 80% of cost came from 12% of claimants, which made self-funding actuarially viable.
- Stop-loss architecture Specific stop-loss at $150,000 per member per year, with aggregate protection at 125% of expected claims.
- TPA selection and PBM carve-out A competitive RFP found a third-party administrator with real-time claims reporting. The pharmacy benefit moved to a transparent pass-through PBM, worth seven figures alone in year one.
- Employee communication A phased campaign framed around expanded benefits, not cost cutting. Open enrollment participation rose 18%.
| $4M+ | annual savings in year two |
| 18% | more open enrollment participation |
| 0% | increase in employee premium contribution |
| 100% | real-time claims visibility |
| For the first time HR and finance could see where every dollar went. The CHRO presented the result to the board as a model for responsible self-insurance. | |
Closing the book on aging claims
A California employer carried workers’ compensation claims that had sat unresolved for years. Reserves had built up to levels threatening the experience modification rate. Without action, the projection pointed to a premium increase above $500,000 at renewal.
What was done, in order
- Inventory and triage Every open claim ranked by reserve, age, litigation status and effect on the modifier.
- Strategic closure planning Settlement strategy, reserve challenges backed by medical evidence, and return-to-work offers where appropriate.
- Carrier stewardship Regular meetings with the carrier’s adjusters to track closure targets and escalate stalled cases.
- Premium impact modeling Each closure scenario modeled against renewal so HR and finance saw the premium effect in advance.
| $500K+ | reserves reduced through closures |
| $500K+ | premium increase prevented at renewal |
| 0 | unplanned surcharges at renewal |
| Workers’ comp cost control is a claims-management discipline: strategic advocacy, financial modeling and sustained accountability between employer and carrier. | |
Eliminating spread pricing
A contract audit showed a traditional spread-pricing arrangement. The PBM billed the plan $340 for a generic drug that the pharmacy was paid $210 for, a $130 spread on one fill. The employer was not negligent. Nobody had shown them what to ask for.
One generic prescription, as billed
Pharmacy was paid$210
Kept as spread$130
Plan was billed$340
What was done, in order
- Contract deconstruction A line-by-line audit quantified spread pricing, rebate retention and administrative fees.
- Pass-through RFP Five pass-through PBMs evaluated on formulary, clinical programs and real-time reporting. The plan pays exactly what the pharmacy is paid.
- Formulary optimization 23 high-cost branded drugs with equivalent generics were identified. Step therapy cut specialty spend 18% in six months.
- Member education A drug cost comparison tool and pharmacist hotline helped members choose mail-order and generics.
| 40% | lower per-member pharmacy cost |
| 100% | of rebates returned to the plan |
| 18% | specialty spend reduction in six months |
| $0 | increase in employee cost-sharing |
| The employer received 100% of manufacturer rebates for the first time, a six-figure credit against plan costs, and now gets monthly drug-level reporting. | |
Every one of these began with a fifteen-minute call.
| Length | Call | What happens | Book |
|---|---|---|---|
| 15 min | Intro call, free | A fit check. Describe the situation and hear whether Claudia can help. | Book |
| 30 min | Brainstorm | Bring one problem. Leave with a point of view and the next two steps. | Book |
| 60 min | Consultation | A working session with your documents, ideally with your CFO, attorney or CPA. | Book |