2025 Renewal Planning 2

January renewals are coming up more quickly than you can imagine.  I am posting this for the benefit of employers and brokers. 

 For employers:  If you are managing your Health Plan within the “new” rules of transparency and disclosure and are shocked by what you see, or maybe do not see, you should reach out to your broker and ask them to bring you solutions that allow you to “see” the data and to make decisions based on that data for the benefit of your members.  Not only is this in your best interest from a cost-benefit perspective, but it may also be your FIDUCIARY responsibility to “be in the know” about these things.

 Is your Plan utilizing a network? Do you have incentives for members to use High-Quality, lower cost providers?  Do you have a medical manager that can help “steer” your member to those?  There are alternatives to “traditional” networks that do NOT have secret deals and “gag clauses” (now disallowed) that can provide full transparency and the highest quality care. Pay attention to the prescription drug costs as saving money here can be a low-hanging fruit of cost containment with the right PBM.

 For brokers:  Become a “trusted advisor!”  Stop relying on spreadsheets with numbers from the BUCAs and do research into innovative plan solutions, starting with an independent Third-Party Administrator (TPA). Find out if they can provide concierge/medical management services that may include direct contracts with high quality facilities and professional providers that are based on a “bottom-up” or Cost Plus process.  Check out the data that is provided—is it clear and understandable?  Also, work with Stop Loss carriers that truly understand the features that are included in the Plan. Many Stop Loss carriers are merely commodities that have very little interest in the underlying cost-management provided in the Plan.  Payment Integrity programs can save big money on not only large claims, but aggregate claims as well.  Aggregate claims are important in any small- to mid-market plan, especially any “level-funded” arrangement.

 Have a great renewal season—there is still time to make a HUGE positive impact!

Give us a call or email and we will get on it!

Revolution…

There is a revolution afoot!  This revolution, like many throughout history has begun at the “bottom” and working its way up—up-market! It is a revolution based on the “revelation” that the cost of offering benefits can be different—lower—than what has been “common practice!”  And it is most obvious in the mid-market arena.

Most of this new “uncommon practice” is being conducted by independent, regional, or local advisors breaking away from spreadsheet-bound legacy carriers with misaligned incentives and moving to transparency, accountability, outcomes, and disclosure.  These are not new! However, because of the NSA and CAA, they are becoming central to the discussion these progressive advisors are now having with their clients in the C-Suite. We can thank the Feds for codifying these common-sense practices, but in reality, many of our more progressive consultants, advisors and TPAs have been providing these things all along. There are hundreds of these advisors and advisor organizations  supported by countless point solutions providing data and outcome accountability.

So what is the difference now? I believe that the pressure on employers to reduce costs is so great that they are finally receptive to wholesale change. In addition, there are new products on the market that take advantage of the new “rules,” such as the required removal of “gag clauses” in carrier, network, and provider contracts. Self-funded health plan sponsors and their designated “named fiduciaries” are waking up to the possibility of member lawsuits.  Employers are asking for claim payment reviews and provider contracts that are based on costs--not Chargemaster make-believe--and getting them!

The employer-sponsored benefit landscape is changing faster than l can recall in my 35 years in the Self-funded space and it is very exciting. Plans are saving money, reducing out-of-pocket costs, improving outcomes, and improving benefits by concentrating on transparency, accountability, outcomes, and disclosure—DATA, something the legacy carriers have but are very reluctant to share!

Keep it up, progressive, creative consultants and advisors—we are creating a revolution! DM me if you want to discuss further!

Plan Balance

The quickly evolving employee benefit regulations have made planning and financing employee health benefits more challenging today than ever before. There are new products, approaches, and efficiencies being introduced almost weekly, and it can feel overwhelming to stay up-to-date.

These new developments are creating challenges in choosing the right TPA, Stop Loss carrier, and other Point Solutions—choices that can have dramatic effects on the cost and efficiency of the plan. Brokers and consultants need to know these “best-in-class” services to deliver the right balance of cost and quality to their clients.

And with all these rapid changes to the industry, there are new challenges to you as a broker or consultant. Are all revenue sources being disclosed? Are all vendor contracts free of "gag clauses?" You need to be prepared for this "new world," and be able to demonstrate fluency in the changes with your business partners and clients.

It is not ALL about balance, but finding the balance between cost, quality, and HR disruption is one of largest hurdles in benefit planning—after the decision to Self-Fund, of course!

Self-Funding Considerations

When rebuilding a Self-Funded plan, it's crucial to consider all of the "point solutions" that may be involved. These can include Rx vendors, Direct Primary Care programs, Disease-specific options, reimbursement applications like RBP or High-performance networks, and more. Integrating these programs into your member engagement plan is key to preventing member disruption.

It's important to ensure that these systems or programs communicate with each other, as miscommunication can lead to issues with cost and quality of care. By acquiring data from the point solutions that support their sales pitch, employers can make sound decisions and get appropriate pricing from Stop Loss.

Remember, the "one phone number" on the card should lead to someone who can provide direction to maximize the benefit, cost, and quality of care. Choose an administrator who can provide many or all of these programs under one roof, or one that does a good job of integrating different vendors into their systems.

Stay informed and make the most out of your Self-Funded plan!

2025 Planning

I am sure many brokers and consultants are beginning to see RFPs for January, especially for larger groups, so it is certainly time to embrace the change. Even large employers, typically “happily” self-funded with an ASO arrangement from one of the “big 4,” but this year should be a turning point for them as well. There is now more information available to them than ever before, should they be motivated to look for it.

There are now resources and tools available to all consultants/brokers and employers that show them exactly how much less they could be paying in claims had they not been “convinced” by someone that a particular national network delivered the best discounts! This opens the door to the obvious question that I have been asking for the last 15 years, “Discounts from what?” Thanks to transparency rules, the answer is now within reach!  It all starts with Self-Funding and DATA, preferably with an independent TPA!

Don’t wait—Now is the time to act—January is very close!

Claims are King

I recently came across a post from a company that was perplexed about not saving any money after transitioning to Self-Funding. While I do not have the specifics of their situation, I can understand the concern. Saving money with Self-Funding is not just about the funding - it's about the CLAIMS!

Here are some key points to consider and questions to ask:

1. Are you using an "independent" TPA--one that is not tied to a BUCA or a traditional network?
2. Are you taking advantage of tools available to identify "unclean," inappropriate, or downright fraudulent claims? A good TPA will have many such tools.
3. Are you utilizing an Alternative Reimbursement Strategy for paying providers? Strategies such as Reference-Based, Value-Based pricing, or any strategy that does not rely on discounts from billed charges can have a huge impact. Even direct contracts negotiated from a "cost plus" perspective can save upwards of 30% on facility claims.
4. Have you redesigned the Plan to take advantage of "new" ideas such as Direct Primary Care, transparent Rx programs...

The list can be much longer, but these points give you a few reasons why your Self-Funded plan may not be saving you much from the fully-insured Plan you left. Having more DATA about the CLAIMS with which to make decisions puts you on the right track, and a good Advisor/TPA can help with the details to make your plan both cost-effective and member-serving!