Before Renewal, Rehearse a Complex Claim
A CFO asks who will help an employee facing a complicated hospital stay. The administrator points to the care-management vendor. The vendor points to a referral process. The stop-loss carrier asks when it will receive notice.
This is a hypothetical meeting, but it is a useful test. Before signing the next renewal, leadership should know whether those answers fit together.
What the latest claims research adds
Sun Life's May 2026 high-cost claims report analyzed more than 70,000 high-dollar medical claims from over 3,300 self-funded employers. Its release identifies additional health conditions, lengthy hospital stays, and injectable drugs as major drivers of claims above $3 million. The source idea is straightforward: a large claim can involve several overlapping needs rather than one isolated diagnosis.
That is an insurer's claims experience, not a forecast for a particular Indiana or Illinois employer. It does, however, raise a useful purchasing question for the coming plan year: how well do the services in the proposal work together?
Run a tabletop exercise before the signatures
Take a fictional employee with a serious illness, an ongoing prescription, and a hospital discharge that requires follow-up care. Use no employee records. Ask the proposed administrator, care-management team, pharmacy partner, and stop-loss representative to walk through their responsibilities.
Start with the first signal. Who receives it? What triggers outreach? How quickly is someone assigned? Then move to the handoff. If one vendor identifies a problem outside its role, who accepts the referral and confirms that it reached the right team?
A referral sent is not the same as help received. Ask each vendor to show the process it can commit to in writing, including what happens when the employee cannot be reached.
Give the employee one clear starting point
Picture someone leaving the hospital with several phone numbers and little energy to sort them out. A benefits package can contain useful services and still be difficult to use.
Leadership can ask for a clear contact route, an explanation of the support available, and a way to resolve conflicting instructions. Clinical decisions belong with the patient and qualified clinicians. The employer's job is to purchase a process that makes appropriate help easier to reach.
For a Midwest business with multiple shifts or locations, test the practical details: can employees reach the service outside normal office hours, and can their families understand where to start?
Connect the service map to the financial map
Self-funding makes this exercise relevant because the employer pays covered claims under its plan. Stop-loss protection depends on the policy's terms; a care-management referral does not establish reimbursement eligibility.
Ask the administrator and carrier to identify notice requirements, documentation responsibilities, and any differences between plan coverage and stop-loss reimbursement. Give finance a separate view of expected payment timing and unresolved reimbursement questions. Keep identifiable clinical information with authorized teams; leadership can review process performance without a patient's medical story.
The point is to expose a missing handoff while it is still a contract discussion. A lower administration fee deserves a closer look if the proposal leaves essential work unassigned.
Measure whether the handoff worked
For the first quarterly review, choose a few measures the vendors can actually produce: time from referral to outreach, unresolved referrals, employee service complaints, and outstanding stop-loss documentation. Agree on definitions and an owner for each measure before launch.
Do not book projected savings simply because a navigation program appears in the renewal. Ask how results will be measured, what comparison will be used, and whether vendor fees are included.
This is a practical conversation for Superior Insurance Advisors and Paul H. Flowers Jr.'s work through Paul.Health: helping business leaders turn a benefits proposal into questions they can evaluate before committing company dollars.
Source: Sun Life, May 21, 2026: findings from its annual high-cost claims report. The operating checklist here is original editorial analysis, not a finding or recommendation attributed to the report. Educational information only; not legal, medical, or tax advice. Plan and policy terms control.
Five questions for the renewal meeting
- Who owns the first outreach, and what starts it?
- Who confirms that each referral was accepted?
- Where does the employee turn when instructions conflict?
- Who tracks stop-loss notices and reimbursement documentation?
- What will leadership review in 90 days to see whether the process worked?
Before approving the renewal, can your vendors walk through one complex claim together and leave you with named owners for every handoff?