Self Funded Platform: Controlling Costs at Renewal
Virginia 376 Employees
One of our broker partners successfully built a block of business
by transitioning clients and prospects to a self-funded
The prior program lacked carrier and network transparency,
claims management and cost containment features, leading to
significant increases in medical stop-loss premiums for these
groups, making self-funding unstable.
Crumdale worked to understand the current suite of vendors
serving the group of accounts to identify improvements that
could be implemented.
Long-term strategy to control costs and stabilize the self-funded consortium.
Stabilize the self-funded consortium and achieve cost savings for the block.
$1.7 Million +
Increased surplus retained from $0 to $1.7 million in one year
Reduced claims spend by 47% over one year
Saved more than
$350,000 in claims through med & Rx intervention
Before & After
|Program Structure||Level Funded (12 equal
payments at annual max cost)
|Level Funded (12 equal payments
at annual max cost)
|Third-Party Administrator (TPA)||Hospital Owned TPA||Independent TPA|
|Network||Local TPA and Hospital
|Pharmacy Benefit Manager (PBM)||TPA Provided||Transparent PBM Contract|
|Medical Stop Loss||Spread between different
|Resolute Underwriting Strategies|
|Surplus||None||100% Retained By Group|
|Claim Review & Monitoring||None||Franklin Health|
|Pharmacy Oversight||None||Franklin Health|
|Data Analytics||None||Franklin Health|
|Patient Assistance Programs (RX)||None||Franklin Health|
|Patient Advocacy / Engagement||None||Franklin Health|
|Plan Document Review||None||Franklin Health|
|ERISA Guidance & Support||None||Franklin Health|
|Compliance Review||None||Franklin Health|
|Data Analytics||None||Franklin Health|
|12 Months Before Crumdale Partners||12 Months With Crumdale Partners|
|# of Employees||376||361|
|Surplus / (Deficit)||($5,847)||$1,779,250|
These groups received $1.7 Million + in surplus.
These groups increased the surplus they retained from $0 to $1,779,250 in just 1 year a 47% reduction in claims spend.
How We Did It
The hospital-owned network and TPa previously in place were not properly aligned with the needs of each employer group or the block itself.
- The network was aligned with the TPA’s
owner, not the underlying employer groups
- A PBM contract with zero transparency
towards prescription drug pricing
- No claims management
- Carrier retained all PBM rebates
- No clinical integration
- Little broker or client control
Crumdale partners’ dynamic solutions enabled the broker to stabilize the self-funded platform, while saving the block $1.7m, offering transparency, and maintaining flexibility. Some of the major changes made included:
- Implemented coalition/block pricing across program vendors.
- Assigned an independent TPA with no ties to the network or hospital systems.
- Implemented Crumdale’s Fiduciary Shield
program to closely monitor prior authorizations for medical services and prescription drugs.
- Analyzed case management notes to engage high-cost claims early in the process.
- Created a well-designed and managed health plan partnered with a stop-loss carrier to expertly manage risk.
- Identified an issue with a high-cost drug before the group had to pay for the first prescription fill and secured the brand name drug at zero cost to the group and member without delay through a manufacturer’s assistance program.
- Implemented immediate claims review before payment by each group to assure that payments were appropriate for the services provided.
- Implemented a coalition-level PBM contract with alternative sourcing for high-cost specialty drug support integrated within the contract.
- Provided a member-level concierge service to help employees find the best doctors at the most cost-effective price.
- Managed the details involved in moving a block of this size, such as member enrollment, ID cards, network disruption, vendor integration, plan document creation, and on-boarding.
- Identified a processed claim that was scheduled to be paid at charges of $49,000 with no discount through a TPA error. After review, the claim was re-priced to approximately $6,000, a group savings of $43,000.