How to turn your claims data into smarter benefits decisions

If your organization is self-funded, your health plan generates something that most fully insured employers never get to see: a detailed record of exactly what your employees used, what it cost, and where the money went.

That's your claims data. And for most HR leaders, it sits in a report that gets opened once a quarter, skimmed, and closed.

That's a missed opportunity. Your claims data is the most direct window into what's driving your health plan costs. Used well, it tells you where to intervene, what's working, and how to make smarter plan design decisions year over year. This guide walks through how to actually read it, what to look for, and what to do when you find something worth acting on.

What is claims data?

Claims data is the record of every medical and pharmacy service your plan paid for during a given period. Every time an employee sees a doctor, fills a prescription, has a procedure, or visits an emergency room, a claim is submitted to your plan for reimbursement. That claim contains information about the service, the provider, the cost, and the member.

For fully insured employers, the carrier owns this data. You pay a premium and the carrier handles everything behind the scenes. You may get a summary report at renewal, but the underlying detail belongs to them.

For self-funded employers, it's different. Your third-party administrator (TPA) processes claims on your behalf, and the data is yours. That access is one of the core advantages of self-funding, and it's only valuable if you know how to use it.

What's actually in a claims report

Claims reports vary by TPA, but most include a consistent set of components. Understanding what you're looking at before you try to analyze it makes the whole process considerably less overwhelming.

Medical claims

Medical claims cover services delivered by providers: office visits, specialist consultations, hospital stays, surgeries, imaging, lab work, emergency care, and more. A medical claims report typically shows:

• Total paid claims by service category
• Claims volume by provider or facility type
• High-cost claimant activity (usually anonymized to comply with HIPAA)
• In-network vs. out-of-network utilization

Pharmacy claims

Pharmacy claims are reported separately from medical and deserve their own close look. According to KFF's 2024 Employer Health Benefits Survey, a third of large employers covering GLP-1 drugs for weight loss expect a significant impact on their plan's prescription drug spending, and that's before accounting for the broader specialty drug pipeline. Your pharmacy report should show:

• Total drug spend by category (generic, brand, specialty)
• Top drugs by cost
• Specialty drug utilization and cost
• Mail-order vs. retail fill rates

Member-level data and HIPAA considerations

Self-funded employers have access to more granular data than their fully insured counterparts, including member-level claims detail. This is powerful for understanding cost drivers, but it comes with important obligations.

Under HIPAA, self-funded employers must maintain a strict firewall between claims data and employment decisions. Your TPA and broker should help you structure data access appropriately. In practice, this means that HR leaders typically work with de-identified or aggregated reports rather than individual employee claims records.

What to look for in your claims data

Knowing what's in the report is step one. Knowing what actually matters is step two. Here's where to focus.

Total claims vs. premium equivalent

Start with the big picture. What did your plan actually pay out in claims versus what you would have paid in premiums under a fully insured arrangement? If your claims are running well below a comparable fully insured premium, that's evidence the self-funded structure is working in your favor. If they're running over, you need to understand why before your next renewal.

Your broker should be able to model a premium equivalent for comparison. This is a standard analytical tool and a good starting point for any claims review.

High-cost claimants

In most employer health plans, a small number of members account for a disproportionate share of total claims. It's common for the top 5% of claimants to represent 50% or more of total plan spend. Your report should flag claimant cohorts above defined cost thresholds, with specific numbers depending on your stop-loss structure.

The goal here isn't to identify individuals. That's both a HIPAA concern and beside the point. The goal is to understand whether high-cost activity reflects acute, one-time events (a surgery, a difficult pregnancy) or ongoing chronic conditions that may benefit from care management support.

Specialty drug spend

Specialty drugs, including biologics, oncology treatments, GLP-1s, and other high-cost medications, are increasingly the single largest line item for self-funded employers. A plan with even one or two members on specialty medications can see pharmacy costs spike significantly.

What to look for:

• Which drug categories are driving the most spend
• Whether members are accessing manufacturer assistance programs that could offset cost
• Whether your PBM formulary is optimized for cost management or just access

If specialty drug spend is a significant portion of your total pharmacy cost, that warrants a deeper conversation with your broker about PBM contract terms and carve-out strategies.

Utilization patterns

How are your employees actually using the plan? High emergency room utilization relative to primary care visits can signal a network access problem, gaps in care navigation, or a population that isn't engaged with preventive care. High out-of-network utilization may indicate a network adequacy issue worth addressing in your next plan design cycle.

Look for:

• ER visit rates relative to urgent care and primary care
• Out-of-network utilization by service type
• Preventive care utilization rates (mammograms, annual physicals, colonoscopies)

Chronic condition prevalence

Conditions like diabetes, hypertension, musculoskeletal disorders, and behavioral health diagnoses are both highly prevalent and highly manageable with the right support programs. If your claims data shows a concentration of spend in any of these categories, that's a signal to evaluate whether your plan is offering the right resources, and whether employees are actually using them.

What to do with what you find

Data without action is just a report. Here's how to translate what you find into decisions.

When claims are running higher than projected

Start by separating signal from noise. Not every spike means something is structurally wrong. Ask:

1. Is this a one-time event? A single high-cost claimant (a cancer diagnosis, a premature birth, a serious accident) can skew a year's worth of data. If the variance traces back to one or two members, it may not reflect a broader problem.
2. Or is it a trend? If costs are running high across the population, that warrants a deeper look. Work with your broker to identify the cost driver and evaluate your options:
   • Adjusting plan design
   • Adding care management programs
   • Revisiting your network
   • Reviewing your stop-loss structure

When pharmacy spend is the problem

Pharmacy costs are one of the most actionable line items in a claims report because there are concrete levers available. Work with your broker to evaluate:

• Whether your PBM contract is structured in your favor (transparent pricing vs. spread pricing)
• Whether a formulary review or prior authorization adjustment makes sense
• Whether a specialty pharmacy carve-out would reduce costs on high-dollar medications
• Whether employees are aware of lower-cost therapeutic alternatives where they exist

When utilization patterns point to a network issue

High out-of-network utilization or heavy ER use relative to primary care often reflects a network problem more than a member behavior problem. If your network doesn't have adequate primary care access in the geographies where your employees actually live, they'll end up in the ER or going out of network by necessity.

Bring this data to your broker and ask them to evaluate network adequacy for your specific employee population. If you're approaching a renewal, it's worth considering whether a different network arrangement, or supplementing your existing network with direct primary care access, would change the pattern.

When chronic conditions are driving costs

Chronic condition spend is both predictable and manageable. If your data shows a meaningful concentration of diabetes, hypertension, or musculoskeletal claims, that's an opportunity to evaluate condition management programs, behavioral health resources, or point solutions that can reduce downstream costs.

The key is connecting the data finding to a specific program intervention rather than treating it as just a number on a report. Your broker should be able to help you evaluate vendors and programs that match your population's actual needs.

How your broker should be using this data with you

A good broker doesn't hand you a claims report and wish you luck. They sit with you in the data, help you understand what you're seeing, and translate findings into a concrete plan.

Specifically, your broker should be:

• Benchmarking your results. How does your plan's cost per member compare to similar employers in your industry and region? Without a benchmark, you don't know whether your numbers are good, bad, or average.
• Identifying intervention opportunities. When a cost driver shows up in the data, your broker should have specific recommendations, not just observations.
• Connecting data to plan design. The whole point of claims review is to make better decisions at renewal. Your broker should be building a direct line between what the data shows and what you change in your plan next year.
• Tracking trends over time. A single month of claims data is a snapshot. Twelve months is a trend. Your broker should be maintaining a longitudinal view so you can see whether interventions are working and where new issues are emerging.

At Nava, this kind of data partnership is central to how we work with clients. We don't just deliver reports. We help HR teams understand what the data is saying and build a plan to act on it.

How often should you be reviewing your claims data?

A consistent cadence matters as much as the quality of the analysis. Here's a simple framework:

• Monthly: Review a high-level summary of claims spend vs. projection. Flag any unusual activity or large individual claims approaching your stop-loss threshold. This doesn't need to be a deep dive — 30 minutes with your broker or TPA report is enough to stay current.
• Quarterly: Go deeper. Review trends by service category, pharmacy spend, and utilization patterns. Compare to prior quarters and prior year. Identify anything that warrants action before it becomes a renewal problem.
• Annually: Full deep-dive before renewal. This is where you connect the full year of claims data to your plan design decisions for the coming year. High-cost categories, underused benefits, network gaps, and PBM performance all belong in this conversation.

Frequently asked questions

What is claims data in healthcare?

Claims data is the record of medical and pharmacy services submitted to a health plan for reimbursement. Each claim contains information about the type of service, the provider, the cost, and the member. For self-funded employers, this data is owned by the employer and processed by a TPA.

What can claims data tell you about your health plan?

Claims data reveals what your employees are actually using, what it's costing, and where spend is concentrated. It can identify high-cost claimants, utilization patterns, chronic condition prevalence, pharmacy spend trends, and network utilization, all of which inform plan design and cost management decisions.

How do self-funded employers access their claims data?

Your TPA produces claims reports on a regular basis, typically monthly, with more detailed quarterly and annual summaries available. Your broker should also have access to this data and be using it to inform their recommendations to you.

What's the difference between medical and pharmacy claims?

Medical claims cover services provided by doctors, hospitals, and other healthcare providers. Pharmacy claims cover prescription drugs dispensed at retail or mail-order pharmacies. Both are tracked separately because they have different cost drivers and different levers for management.

How do I know if my health plan costs are too high?

Benchmarking is the most reliable way to answer this question. Your broker should be able to compare your plan's cost per member to industry benchmarks from sources like the Kaiser Family Foundation or EBRI. If your costs are significantly above benchmark for your industry and employee demographics, that's a signal worth investigating.

Ready to put your claims data to work?

Nava's advisors help self-funded employers do more than read their reports. We help you understand what the data means and build a plan to act on it. Talk to a Nava advisor.