Self Funded Platform: Controlling Costs at Renewal

The Situation

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

$350k +

Saved more than
$350,000 in claims through med & Rx intervention

Before & After

  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
National Network
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

The Results

  12 Months Before Crumdale Partners 12 Months With Crumdale Partners
# of Employees 376 361
Aggregate Claims $2,789,041 $1,413,071
Claims, PEPY $7,418 $3,912
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.