Self Funded Platform:
Controlling Costs at Renewal
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 Network | National Network |
| Pharmacy Benefit Manager (PBM) | TPA Provided | Transparent PBM Contract |
| Medical Stop Loss | Spread between different carriers | 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 |
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.
Pricing
FAVORABLE DISCOUNTS, TERMS, AND CONDITIONS
Stability
DECREASE RENEWAL VOLATILITY
Control
ALLOWS FOR STRATEGIC PLANNING & FINANCING
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
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.
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