Accurate Premiums are Only Part of the Equation

Accurate Premiums are Only Part of the Equation : How Self Bill Pro Provides a Better Way Forward

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Most plan sponsors are already familiar with the two primary billing models – list bill and self-bill. With list billing, the carrier generates a monthly invoice based on their enrollment records, records that depend on EDI file feeds to stay current. When issues with those feeds arise, it can lead to overpayments, reconciliation headaches, and eligibility discrepancies that can surface at exactly the wrong moment. Self-billing addresses this by putting the plan sponsor in control, enabling you to calculate and remit premiums based on your own enrollment data, eliminating theback-and-forth and reducing reconciliation overhead significantly.

For most organizations, the shift to self-billing is a meaningful operational improvement. But it does not close every gap.

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The Hidden Limitation

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Self-billing sounds like the obvious answer, and for premium remittance, it is. But there is a critical gap that often goes unaddressed,what happens at the point of a claim?

In a standard self-billing arrangement, the plan sponsor controls the premium calculation, but the carrier still needs to adjudicate claims as they come in. And when a claim is submitted, the carrier needs to verify eligibility in real time. Is this person still covered? Under which plan? As of what date?

If the carrier's eligibility data is not current, the claim is flagged for manual review, causing delays. This can lead to the plan sponsor receiving unwanted calls and emails, carriers being bogged without recent data, and the members claim experience suffering.

The carrier simply does not have the eligibility data it needs at the moment a claim arrives. This is not a flaw in the self-billing concept but a gap that can be resolved.

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A Path Forward

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The answer is not to abandon self-billing; it is to close the eligibility data gap before it becomes a problem at the claim level.

This is precisely where Self Bill Pro changes the equation, by providing structured claims eligibility files to the carrier alongside the calculation of your self-bills. The carrier receives current,accurate member eligibility data proactively, not as a by product of a claim being filed, but well before one ever arrives.

The result is a model where:

• Premium remittance stays in the plan sponsor's control, maintaining all the efficiency benefits of Self Bill Pro calculating the bill using the most accurate data
• Carrier eligibility records stay current, dramatically reducing manual interventions
• The interaction between group and carrier at the point of a claim is minimized, because the carrier already has what it needs

It is the logical evolution of self-billing: taking the administrative control you have with premium remittance and extending it to the claims process.

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The Takeaway for Employers and Plan Sponsors

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The employers who run the most efficient benefits operationsare not just paying premiums smarter. They are making sure the entire data ecosystem, from enrollment through adjudication, is working from the samecurrent, accurate picture of who is covered.

If your organization is still navigating the reconciliation headaches of list billing, or if you are already on a self-billing model but finding that claim issues persist, Self Bill Pro is here to support your needs.

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Matthew Oliver

Director of Value-Added Services, Self Bill Pro

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