How to Go from High-Dollar to High-Value: Five Strategies for Claims Cost Control
If you oversee claims, whether in workers’ compensation or auto casualty, you know the pressure: rising medical costs, extended recovery durations and increasing litigation can strain budgets, disrupt operations and threaten the trust you’ve worked hard to build. Every decision you make has a ripple effect on both financial performance and the well-being of the people involved.
The most effective leaders don’t wait for costs to spiral. They take control early, apply expertise at the right moments and build processes that deliver better outcomes while protecting resources.
Here are five proven strategies, backed by real-world, measurable results, that show how proactive action can help you reduce costs, shorten recovery times and strengthen confidence in your organization’s ability to manage claims in both workers’ comp and auto casualty.
1. Cross-Functional Collaboration to Drive Unmatched Cost Savings
The Savings Opportunity
Complex billing issues that often accompany high-dollar claims can be converted into deeper, systemic savings.
The Proven Solution: Reduce Complex Hospital Bills
When a large insurance carrier received a $4.17 million hospital bill, they believed additional savings opportunities still existed. They turned to their client success manager for urgent support. Enlyte’s multi-skilled teams acted immediately to provide a comprehensive review and negotiation strategy:
- Rapid response: Bill review specialists engaged within hours to review and validate charges
- Expert analysis: Pharmacy leadership uncovered a critical billing error, mispriced rabies immunoglobulin, valued at over $800,000
- Focused negotiation: Targeting the highest-value issue, expert negotiators quickly engaged the hospital’s billing partner to secure adjustments
The Result
Financial exposure reduced from $4.17 million to just $214,000—a 95% reduction.
Takeaway
Don’t just settle for a win for your balance sheet. The combination of rapid response with deep clinical knowledge and skilled negotiation helps protect your resources under pressure while preserving focus on employee care.
2. Clinical Oversight to Prevent Unnecessary Treatment Costs
The Savings Opportunity
Physical therapy is essential for recovery, but without oversight, overextended treatment can drain resources and delay return-to-work timelines.
The Proven Solution: Eliminate Unneeded Physical Therapy Visits
A national managed care organization implemented the systematic review of additional physical therapy authorization requests using Enlyte’s licensed physical therapists to provide informed recommendations on whether patient discharge was appropriate or continued therapy should be approved. With clinical oversight these reviews uncovered multiple unnecessary PT requests including:
- 24 additional PT visits were ordered for a patient with a post finger fracture who had already completed 21 PT visits. A clinical review was completed and discharge was determined to be appropriate, avoiding the additional 24 unnecessary visits
- A patient with an ankle sprain was authorized for 14 PT visits but only attended four. When additional PT was ordered, a clinical review was completed and determined discharge was appropriate and the patient was ready for return to work
The Result
Within a month, Enlyte’s clinical team reviewed 23% of the client’s requests for additional PT and captured 53% savings through reductions in the number of visits authorized compared to the number of visits ordered.
Takeaway
With access to dedicated licensed physical therapists, your team can quickly obtain insight into medical progress, treatment adherence and recovery timelines for more informed decision-making. This collaboration reduces recovery times and promotes overall PT program savings.
3. Integrate Pharmacy Benefit Management to Deliver Double-Digit Savings
The Savings Opportunity
As payers face significant challenges controlling high-cost abusive drug pricing and preventing unnecessary dispensing, integrating pharmacy benefit management (PBM) with bill review (BR) helps you take control of unmanaged spend, regardless of the dispensing channel, to capture greater savings.
The Proven Solution: Gain Control Over Out-of-Network Pharmacy Bills
After implementing Enlyte’s integrated PBM and BR solution, a national employer achieved:
- 100% management of drug utilization through clinical oversight, risk scoring and utilization controls
- Integrated risk alerts to optimize clinical outcomes denied 23% of fills otherwise paid through bill review
The Result
The program delivered a 29% reduction in pharmacy spend, including a 9%-point decrease on older claims and identified 25% more high-risk cases.
Takeaway
When traditional PBMs focus solely on network discounts, out-of-network spend is missed. Managing 100% of in- and out-of-network drug utilization and applying clinical reviews, risk scoring and utilization controls to each and every claim achieves better claims impact with greater cost containment.
4. Integrate Utilization Review and Bill Review to Prevent Claim Leakage
The Savings Opportunity
Manually cross-referencing incoming bills to utilization review (UR) determinations is labor-intensive and error-prone, leading to payment of unauthorized treatments. UR automation ensures consistent, accurate decisions and prevents claim leakage.
The Proven Solution: Stop Unnecessary Payments Before They Happen
A large carrier adopted Enlyte’s Utilization Review Decision Manager (URDM), which:
- Embedded UR determinations directly into the claims system
- Applied intelligent logic to automatically approve, deny or flag bills based on treatment authorizations
- Reduced manual adjuster touchpoints and improved processing speed
The Result
The program saved $2 million in one year, representing a 41% increase in bill review savings and impacting 5% of total bill volume through automation.
Takeaway
This streamlined approach not only improves provider adherence to authorized treatment guidelines but also frees up your adjusters to focus their time and expertise on higher-value claim activities.
5. Drive Better Outcomes and Savings with Total Program Integration
The Savings Opportunity
Total program integration brings together multiple cost-containment strategies under one coordinated approach, with each delivering distinct value. While powerful on their own, together they represent a comprehensive model that drives measurable savings and improves outcomes across the claims process.
The Proven Solution: Integrate Telephonic Case Management and Bill Review
In its first year adopting an integrated telephonic case management (TCM) and bill review program, a large employer saw nearly instant benefits:
- Most TCM referrals occurred within 90 days of injury, allowing case managers to proactively resolve issues before delays caused claim escalation
- Full-duty return-to-work times dropped 30%, saving 16 days on average
- Early TCM intervention provided support, advocacy and engagement with the injured employee. By building trust and offering guidance at the outset of a claim, case managers reduced uncertainty, frustration and fear which are key drivers of litigation. This proactive relationship-building directly contributed to an 87% reduction in attorney involvement
At the same time, advanced bill review tools delivered robust cost controls, with savings across multiple channels:
- FairPay Flex, or specialty bill review, saved $13 million by capturing savings on bills that received little to no fee schedule deduction, savings that would have been missed without its implementation
- Surgical Implant Cost Containment saved $1.9 million by analyzing implant charges against a proprietary rate database to drive fair pricing beyond typical bill review. This strategy delivered significant savings on high-dollar surgical procedures that otherwise would have carried inflated costs
- Negotiation savings delivered $577,000 through prompt-pay incentives, strategic approaches and data-backed negotiations, capturing additional savings on bills outside standard review channels
The Result
The integrated program delivered over $14 million in savings in the first year of program implementation while improving injured employee outcomes, reducing costs and minimizing legal exposure.
Takeaway
Early intervention isn’t just a medical strategy; it’s a relationship strategy. Establishing trust and advocacy at the start of a claim makes litigation less likely, while integrated bill review ensures every savings opportunity is captured. Together, these approaches demonstrate how a total program integration model reduces costs, improves outcomes and strengthens confidence across the claims process.
Lead with Confidence Across Every Claim
Reducing costs on casualty claims isn’t about cutting corners, it’s about working smarter. By integrating proven solutions, cost containment becomes more than a defensive measure, it becomes a way to transform challenges into opportunities. By implementing one or more of the five strategies above, you can capture additional savings, improve outcomes and set your program up for long-term operational excellence.
Interested in putting these strategies to work for your claims program?
Contact us today to learn more and see how Enlyte can help you achieve measurable savings and better outcomes.
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