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District hears year-one claims analysis: high-cost cases drove 37.8% of spending
Summary
USI and UMR presented a deep-dive of the district's first full plan year with UMR (May 2024'Apr 2025), showing high-cost claimants responsible for $11.4 million (37.8%) of plan spending and announcing a 250-claim medical audit to inform future benefit strategy.
UMR and broker USI presented a year-one analysis of Saint Charles Parish Public Schools' self-insured medical plan, telling the board that a small group of very expensive claims accounted for a disproportionate share of cost.
"High cost claims accounted for 37.8% of our total plan spend last year, which accounted for a total cost of $11,400,000," UMR's lead presenter said, summarizing the executive findings. The consultants said 104 members met the plan's high-cost threshold (>$50,000 combined medical and pharmacy) and that those members represented under 3% of the population but an outsized share of dollars.
Presenters said the district became self-insured in 2022 (Humana) and moved to UMR effective May 1, 2024. To validate and explore the drivers behind outlier claims, the district has contracted BMI to perform a stratified random medical claims audit that will sample 250 claims; UMR estimated the audit will take five to seven months with an expected report in April 2026.
Board members asked whether multiple claims from a single person could appear in the sample and how the audit's stratified sampling would handle claim size and frequency; presenters explained the methodology is claim-based and designed to capture a wide range of claim sizes and types. USI said it will bring supplemental year-over-year financial comparisons to upcoming renewal discussions to help determine whether plan design or program changes are warranted.
