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!