Winning the Bid:
How Boutique Beat National
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 | CP Integrated Health |
| Pharmacy Oversight | None | CP Integrated Health |
| Data Analytics | None | CP Integrated Health |
| Plan Document Review | None | CP Integrated Health |
| ERISA Guidance & support | None | CP Integrated Health |
| Compliance Review | None | CP Integrated Health |
| Patient Advocacy / Engagement | None | CP Integrated Health |
| Alternative Funding Programs (RX) | None | CP Integrated 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.
Pricing
FAVORABLE DISCOUNTS, TERMS, AND CONDITIONS
Stability
DECREASED RENEWAL VOLATILITY
Control
ALLOWS FOR STRATEGIC PLANNING & FINANCING
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.
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