EMPLOYERS REVERSING THE TREND
Learn how to improve quality and lower your healthcare spend by 30-50% by understanding the data, cutting out middle players, and taking control of your healthcare spend!
EMPLOYER SUCCESS STORIES
SEIU 32BJ Union
The SEIU 32BJ Union saves $100 million on healthcare with the help of price transparency.
State of Montana
Montana saves $121 million on healthcare by contracting directly with hospitals using a percentage of Medicare rates.
Ashtabula Area City Schools
Ashtabula school district saves $2.4 million dollars in healthcare costs in first year after switching to direct contracting.
Osceola School District
The school system estimates savings to its taxpayers of $6 million in its first year of direct contracting.
EMPLOYER HOW-TO: FOUR STEPS TO ACHIEVE SIGNIFICANT HEALTHCARE SAVINGS
STEP 1: THOROUGHLY REVIEW CONTRACTS
Avoid hidden fees and provisions that hinder cost recovery:
“Claims payment may include fees paid to third party vendors, of which Claims Administrator may hold an ownership interest.”
“Claims Administrator may have contracts with Network Providers or Vendors that limit their right to recover overpayments."
“Claims Administrator may pay a provider more than billed charges."
“Claims Administrator is not liable for recoveries it does not successfully recover, including recoveries for Claims Administrator errors in paying claims."
Avoid conflicts of interest and provisions favoring the Claims Administrator:
“Claims Administrator contracts with manufacturers for rebates and manufacturer administrative fees on its own behalf and for its own benefit, and not on behalf of Employer.”
“Employer acknowledges that unintentional administrative errors may occur… Claims Administrator will not be required to enter into litigation to obtain a recovery… nor will Claims Administrator be required to reimburse the Plan.”
“Claims Administrator may receive remuneration for selling Employer's plan data to other parties for use in research, monitoring, benchmarking, etc.”
STEP 2: PROACTIVELY GATHER PRICING AND CLAIMS DATA FROM THIRD PARTY ADMINISTRATORS (TPA), PHARMACY BENEFIT MANAGERS (PBM), AND CONSULTANTS.
Submit a Demand Letter to your TPA’s, PBM’s, and consultants to receive all negotiated prices and claims data as fiduciary of your employees’ plan.
STEP 3: ANALYZE PLAN DATA AND CONTRACTS.
✔ Consider engaging a third party to reprice a year of medical claims data at Medicare Rates.
✔ Engage a prescription analytics company to scrub pharmaceutical claims for potential savings.
✔ Identify and investigate overcharges, payment errors, and adjudication anomalies, and pursue recoveries.
STEP 4: IDENTIFY AND IMPLEMENT SAVINGS OPPORTUNITIES.
✔ Re-negotiate service provider contracts to align vendor performance with goals, or go to RFP for new partners.
✔ Eliminate middle players; contract directly for fairly priced, high-quality hospitals and providers.
✔ Implement fair, transparent Reference Based Pricing model; agree to pay a percentage of Medicare Rates.
✔ Consider Centers of Excellence, steering employees to high quality, lower priced providers.
✔ Implement a transparent, pass-through pharmacy benefit, carved out of the medical benefit.
✔ Manage drug formulary, using Waste Fee Drug designs, Biosimilars, Single Source Generics.
✔ Provide enhanced primary-care to lower plan costs and improve health outcomes.
✔ Update plan documents & benefit design to safeguard fiduciary role and eliminate non-value-added programs.
