High-Cost Claim Management
Supporting complex health situations
Intensive support for employees facing serious health conditions that generate significant claims
Why does high-cost claim management matter?
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A small number of individuals generate most healthcare costs. These employees face serious health challenges and need intensive support. Proper management improves their care while containing costs for the plan.
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See where your benefit plan is leaking
Find out what gaps exist — and what you can do without changing your plan.
We'll show you where money is leaking, risks are growing, and what you can fix within your current structure. No pressure to change brokers, carriers, or benefit design. Just clarity.
- Gap analysis based on your actual plan structure
- Clear findings you can share with your broker
- Recommendations that layer on — no disruption required
Care Coordination
Intensive coordination for complex cases ensures nothing falls through cracks. Multiple providers, multiple treatments—we keep everything connected.
Treatment Optimization
Guidance on treatment options, including centers of excellence, clinical trials, and evidence-based alternatives.
Cost Containment
Identifying cost reduction opportunities that don't compromise care: facility selection, billing accuracy, alternative treatments.
Ongoing Monitoring
Continuous monitoring of high-cost cases to anticipate needs and prevent escalation.
What is High-Cost Claim Management?
High-Cost Claim Management provides intensive support for employees with catastrophic or complex health conditions that generate significant healthcare costs.
The top 5% of claimants typically generate 50%+ of plan costs. These individuals face serious health challenges: cancer, transplants, complex chronic conditions, severe injuries. They need support that routine services don't provide.
We provide intensive care coordination, treatment guidance, and cost management that improves their experience while protecting the plan.
Why Do High-Cost Cases Need Special Attention?
Most employers renew their health plans year after year without questioning the underlying assumptions. Brokers present options, carriers set rates, and leadership approves budgets based on incomplete information.
The result? Companies overpay for benefits employees don't use while missing coverage gaps that create real risk. They accept premium increases as inevitable rather than addressable. They lack visibility into where their money actually goes.
A Healthcare Risk Assessment changes that. It gives you the data and insight to make informed decisions, negotiate from a position of strength, and take control of one of your largest operating expenses.
How It Works
High-cost claim management provides intensive support for complex cases.
Identification
Identifying high-cost cases through claims monitoring, notifications, and care team referrals.
Assessment
Assessing the situation: condition, treatment plan, care coordination needs, and cost management opportunities.
Intervention
Implementing appropriate interventions: care coordination, treatment optimization, billing review, provider selection.
Ongoing Management
Continuing to manage the case throughout treatment, adjusting approach as circumstances change.
When Are Cases Identified for Management?
Cases are identified through:
• Claims approaching stop-loss thresholds
• Complex diagnoses flagged by care teams
• Hospital notifications for serious conditions
• Self-referral from employees or family
• Proactive claims monitoring
Where Does Management Occur?
Management spans all care settings:
• Inpatient hospital care
• Outpatient treatment coordination
• Specialty care navigation
• Post-acute transitions
• Ongoing chronic condition support
Who Benefits from High-Cost Management?
Both individuals and plans:
• Employees receive better coordinated care
• Complex situations are navigated effectively
• Plans achieve cost containment
• Stop-loss recoveries are optimized
• Everyone benefits from quality improvement
See What Our Customers Are Saying
"What could have been data driven, was soon a conversation. Over 3 years with the best coaches, listeners, advisors you could ask for. If Monique didn't have an answer readily, she would note it, research it, and then update you on the answer. Always a positive meeting. Highly recommend!"
— Sue D.
“Our Medical Insurance Premiums were Out of Control! Thanks to Weltrio and their amazing team of healthcare experts, Weltrio is my single most-profitable cost center!”
— Cayuse CEO
Everything You Need to Know
At Weltrio, we are a medically trained team that works with HR and benefits partners at companies of all sizes to improve healthcare quality, reduce risk exposure, and optimize costs. We work within your existing plan structure—providing employers with clarity, trust, and transparency at every step. Whether you're upgrading your benefits plan or building from scratch, we've got you covered.
Is this the same as telemedicine?
No. Clinical support provides guidance and triage, not diagnosis or treatment. We help employees decide when and where to seek care.How many nurses will be assigned to our company?
Assignment depends on your company size and typical utilization. Smaller companies may share a primary nurse with backup coverage. Larger organizations get dedicated teams. Either way, employees experience consistent relationships with clinical professionals who know them.Who answers calls in the middle of the night?
Board-certified nurses from your Weltrio clinical team. We staff night shifts with experienced nurses who have full access to your company's benefits information and employee interaction history. It's not an outsourced answering service.What protocols do nurses use for triage?
Our nurses use evidence-based clinical decision support protocols developed from emergency medicine and primary care best practices. These protocols are regularly updated based on current medical guidelines and are customized for telephone/virtual assessment settings.How much does an unnecessary ER visit actually cost?
Average ER visits cost $2,200 or more—even for minor issues. Add lab work, imaging, or specialist consultation and costs climb quickly. The same conditions treated at urgent care typically cost $150-300, and telehealth visits run $50-75.
