Winning the Bid:
How Boutique Beat National
The Situation
Healthcare Client New Jersey 421 Employees
One of our broker partners runs a boutique brokerage firm. One of their long-standing clients decided to do their due diligence and invite in a large national brokerage house to run an analysis on market opportunities for renewal.
The employer group is a specialty pharmacy consulting company in the Northeast that was offering a fully insured medical and prescription drug program since 2004 with Blue Cross.
In the midst of a worldwide pandemic, the employer group received a 40% renewal increase from their insurance carrier.
The employer group questioned the merits of such an increase and wanted to understand their claims data and the details of the contracts governing their plan – particularly the pharmacy
benefits contracts.
Minimal claims information was made available and the contracts were completely unavailable.
Goals
Client:
Save money and gain transparency and flexibility in the plan.
Broker:
Win the bid. Implement both a short-term and long-term solution/strategy.
$1.3 Million +
Saved more than $1.3
million vs renewal
2%
Showed a 2% increase vs
current rates
4 Members
Pre-identified 4 members
for alternative med & Rx
savings programs
Before & After
| Before | After | |
| Program Structure | Fully Insured (12 equal premium payments) | Self-Funded |
| Third-Party Administrator (TPA) | Blue Cross | Independent TPA |
| Network | Blue Cross | National Network |
| Pharmacy Benefit Manager (PBM) | Blue Cross | Transparent PBM Contract |
| Medical Stop Loss | Blue Cross | Resolute Underwriting Strategies |
| Claim Review & Monitoring | None | Franklin Health |
| Pharmacy Oversight | None | Franklin Health |
| Data Analytics | None | Franklin Health |
| Plan Document Review | None | Franklin Health |
| ERISA Guidance & support | None | Franklin Health |
| Compliance Review | None | Franklin Health |
| Patient Advocacy / Engagement | None | Franklin Health |
| Alternative Funding Programs (RX) | None | Franklin Health |
| Data Analytics | None | Franklin Health |
The Results
| Incumbent (2020) | Incumbent Renewal (2021) | Incumbent Renewal (2021) | |
| # of Employees | 421 | 421 | 421 |
| Max Spend | $3,523,773.60 | $4,941,438.36 | $3,624,073.97 |
| Spend, PEPY | $8,370.00 | $11,737.38 | $8,608.24 |
| Expected Spend | $3,523,773.60 | $4,941,438.36 | $3,002,914.51 |
| Differential @ Max | + 40% | + 2% | |
| Differential @ Exp | + 40% | -14% |
The group saved $1.3 Million @ max vs renewal.
The group received a 2% renewal @ max and a 14% decrease @ expected.
How We Did It
The client had many Issues with their prior fully insured Blue Cross plan.
- Lack of alignment between carrier and
employer - Zero transparency on medical and pharmacy claims
- No claims management
- Carrier retained all PBM rebates
- No clinical integration
- Little broker or client control
Crumdale partners’ dynamic solutions enabled the broker to rescue the account and save the client $1.3m, while creating greater transparency and flexibility. Some of the major changes made included:
- Implemented Crumdale 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.
- Implemented payment integrity for immediate claims review prior to payment by each group to assure that payments were appropriate for the services provided.
- Implemented a coalition-level PBM contract with alternative sourcing opportunities 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.