Winning the Bid:
How Boutique Beat National
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|
|Incumbent (2020)||Incumbent Renewal (2021)||Incumbent Renewal (2021)|
|# of Employees||421||421421|
|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.
FAVORABLE DISCOUNTS, TERMS, AND CONDITIONS
DECREASE RENEWAL VOLATILITY
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
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.