High-cost medical claims are hitting harder and more often, putting increased pressure on benefits advisors to protect their clients' budgets and keep plans sustainable. According to recent projections, medical cost trend is holding at 8.5% for the group market, the highest in more than a decade, driven by rising inflation, runaway pharmacy costs and a 45% surge in behavioral health claims. For self-funded employers, the financial pressure is mounting, especially in high-dollar categories like cancer, cardiology and dialysis, where claims are both frequent and financially burdensome.
Benefits professionals are stewards of plan sustainability and financial integrity. That means they must not only react to high-cost claims, but recognize red flags early and implement cost containment strategies before those claims escalate. Here's how advisors can help their clients protect their benefits budgets without sacrificing care quality.
Cancer care: containing costs without compromising outcomes
Cancer-related claims are among the most financially burdensome for self-funded plans. Costs often spike due to high-priced specialty drugs, prolonged treatment cycles and facility-based care. Benefits advisors should guide employers toward proactive measures, including:
- Early identification: Implementing “trigger codes” to flag potentially high-cost treatments or claims at the onset can help plans intervene earlier and avoid runaway spending.
- Claims negotiation: Out-of-network cancer care often comes with inflated charges. Skilled negotiators can challenge these and bring pricing in line with fair market rates.
- Pharmacy benefit oversight: Specialty drugs, including oncology treatments, continue to drive overall drug spending. Advisors should ensure plans leverage pre-authorization, site-of-care redirection and rebate optimization.
- Independent reviews: When high-dollar treatments are recommended, external medical reviews by board-certified oncologists can validate medical necessity and help enforce plan language regarding experimental therapies.
These types of cost spikes, especially tied to infused or hospital-administered drugs, should prompt immediate review for off-label use or missing documentation, reinforcing the importance of vigilant oversight from benefits advisors.
Cardiology claims: spot the hidden traps
Cardiology claims often involve high-cost surgical interventions and complex billing practices. Advisors should stay alert to:
- Assistant surgeon charges: It's common for assistant surgeons to bill at inflated rates. Advisors should ensure payments align with industry norms, typically 16%–20% of the primary surgeon’s fee.
- Unbundling and coding errors: Frequently, cardiovascular procedures are fragmented into multiple line items to increase reimbursement. Detailed line-item reviews can correct this.
- Missed multiple procedure discounts: When multiple procedures are performed during the same session, appropriate reductions should be applied to secondary procedures.
Cardiology claims submitted without detailed charge breakdowns should raise immediate concern, these often signal bundling errors or duplicate billing that require further review. Staying ahead of these patterns is key to controlling unnecessary cost escalation.
Dialysis: the silent drain on employer health plans
Dialysis is a recurring, high-dollar treatment that can strain plan budgets over time, especially when billed out-of-network. Advisors can mitigate financial exposure through:
- Reference-based pricing (RBP): Aligning payments to a percentage of Medicare rates can help stabilize and reduce overpayment risk for dialysis services.
- Network steering: Not all dialysis centers charge the same. Plans should direct members to contracted or lower-cost providers when possible.
- Claims review and repricing: Out-of-network dialysis claims often include inflated line items. Close review can surface savings opportunities and identify billing errors.
- Medicare as secondary payer programs: For qualifying patients, employers should explore flat-fee per claim programs that utilize Medicare as the secondary payer. This strategy can reduce out-of-pocket exposure and bring greater predictability to dialysis costs.
Long-term dialysis claims without negotiated rates or itemized bills should be flagged immediately, early intervention here can make a substantial difference in long-term cost containment.
Behavioral health: driving value through smart design
Behavioral health has emerged as a significant focus area, not just due to rising demand but because of its proven potential to reduce overall medical spending when managed strategically. A 2025 meta-analysis of 19 employer-sponsored behavioral health programs found that access to high-quality mental health care generated a 2.3:1 return on investment, equating to $159 in net savings per member per month. These programs, which offered up to 12 free psychotherapy or medication management sessions per year, consistently reduced total health care costs across diverse industries and employee populations.
For benefits advisors, this finding is both a warning and an opportunity. Behavioral health services can drive financial savings, but only when plan design supports effective engagement, appropriate utilization and clinically sound delivery. That means going beyond network adequacy and ensuring mechanisms are in place to:
- Guide employees toward evidence-based care
- Monitor provider quality and credentials
- Avoid unnecessary overutilization or fragmented treatment
The same study found that outcomes improved when care was coordinated through centralized systems with real-time data tracking and patient-provider matching. These elements helped reduce the number of sessions needed while improving results, further enhancing ROI and controlling spend.
With behavioral health needs rising and aggregate costs increasing, benefits advisors must view mental health not just as a cost center but as a lever. When structured properly, behavioral health benefits can deliver measurable savings, support employee well-being and strengthen the overall value proposition of the health plan.
Tools that make a difference
Today’s self-funded employers and their benefits partners have more advanced tools than ever to manage high-cost claims but the key is using them proactively, not reactively. When integrated strategically, these resources can help curb financial leakage, prevent overpayment and reinforce plan integrity.
Claims negotiation by attorney-led professionals using both proprietary and published pricing benchmarks is also essential. This level of expertise can generate significant savings on large-dollar claims, particularly for out-of-network or complex procedures.
Line-item bill review remains one of the most effective defenses against excessive charges. By scrutinizing detailed claim data, employers can catch unbundled services, duplicate billing and inflated costs that might otherwise pass through unnoticed.
Independent dispute resolution (IDR), a process outlined under the No Surprises Act, provides a structured path to contest and resolve disputed charges with providers, particularly for out-of-network claims that may fall outside normal pricing benchmarks.
Data analytics plays an increasingly critical role. By analyzing historical claims data, plans can uncover recurring cost drivers, identify outlier providers and flag concerning billing patterns. Many health plans now utilize AI-powered analysis, benchmarking and scenario modeling to strengthen their negotiating positions and better manage rising inpatient costs.
Prepayment review adds another layer of defense, allowing plans to intercept questionable charges before they’re paid, eliminating the need for expensive clawbacks or downstream audits.
For benefits advisors, understanding and leveraging these tools is essential to protecting plan assets and delivering measurable value to clients.
The benefits advisor’s role: more than plan design
In today’s cost-sensitive environment, benefits advisors must go far beyond traditional plan design to deliver meaningful, ongoing value. Their role has evolved into that of a strategic partner, one who actively protects client budgets and ensures the long-term health of self-funded plans.
That means educating employers about how high-cost claims can disrupt financial forecasts, impact stop-loss thresholds and drive up renewals. Advisors should also champion stronger claims oversight, advocating for tools such as prepayment review, independent clinical audits and line-item bill analysis, measures that help catch billing discrepancies before they become financial liabilities.
Collaboration is equally important. Advisors can coordinate with specialized vendors for support in negotiation, repricing and clinical validation. These partnerships can uncover savings that might otherwise be missed and provide expert guidance through complex claims.
Tracking and reporting outcomes should also be part of the advisor’s toolkit. Demonstrating the financial impact of proactive strategies, through savings benchmarks, resolution timelines and audit results, reinforces credibility and gives employers clear proof of value.
Ultimately, the advisor’s involvement shouldn’t end at implementation. Vigilance, accountability and continuous optimization are what keep self-funded plans viable, sustainable and fair for both employers and employees.
Cost containment can’t be treated as a one-time project, it must be embedded as an operating principle. For advisors, that means staying one step ahead of rising claims, championing smarter management strategies and guiding clients toward decisions that preserve both their financial stability and care quality.
Bruce D. Roffé, P.D., M.S., H.I.A., is the President and CEO of H.H.C Group, a nationally recognized healthcare consulting firm he founded in 1995. With over 40 years of experience in healthcare cost management and pharmacy, Dr. Roffé has led H.H.C. Group to provide critical cost-containment solutions, including independent review, claim repricing and dispute resolution for insurers and state entities.
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