Part 1  The Network Maximizer

Provider network discounts can vary as much as 15% by carrier in particular regions of the country. Determining the most efficient network based on your company’s utilization is the first step of your healthcare plan risk management process. The objective of this analysis is to compare the expected discounts under your current provider network with the projected discounts that you can achieve utilizing the different networks that are available to you. For example, on $1,000,000 of in-network healthcare claims, Network A yields a 40% discount. This results in $600,000 of net claims payable by your company. Network B yields a 50% discount resulting in $500,000 of net claims payable by your company, or a $100,000 savings.  

Some networks, such as Blue Cross/Blue Shield (BCBS), also charge you a Network Access Fee for claims incurred by your employees outside of your home state. For example, if your company is contracted with BCBS of Michigan and your employee receives in-network care in Florida, you will pay BCBS of Florida a Network Access Fee equal to 10% – 15% of the billed charges. This fee is typically buried in the claims cost and often goes undetected. If a significant part of your employee population works outside of your home state, then this fee can amount to significant dollars.

A network analysis will make the financial dynamics of your network transparent. This analysis will give you a clear, unbiased assessment of the discounts and fees associated with the network alternatives in your region, empowering you to make the best decision. Our actuarial consultant, Milliman, will provide this portion of the analysis. Annual Estimated Savings:  0-15%

Part 2  The Plan Design Advantage

Proper plan design ensures that your employees receive the right care from the right provider at the right time. This study, performed by Milliman, will evaluate your current plan design and offer recommendations on various changes to ensure that your employees are motivated and empowered to select the best care. 

You will be provided with measurements of the effect that the various plan design changes will have on your cost to provide these benefits. The plan design features illustrated include: copayments, deductibles, out of pocket maximums, benefit limitations, etc. Your analysis will also focus on the importance of preventive services, including illustrated costs of first dollar coverage for such care. 

The richness of your current plan design(s) will be compared with those that are offered by other contractor groups. A carefully designed benefit plan will encourage proper utilization, improve the health of your employees and reduce your overall costs. Annual Estimated Savings:  3-5%

Part 3  The TPA Contract Matrix 

There are multiple items in your TPA contract that are negotiable. ACBG will review your current TPA contract and identify areas for improvement. A well-tuned TPA contract can place 20% or more of your carrier’s fees at risk. We will make our observations and recommendations on a number of different areas. 

Items reviewed include:
• Performance Guarantees – these can be written into your contract to ensure best-in-class performance from your carrier with a portion of their fees at risk. 
• Network Discount Guarantees – be certain your carrier is achieving the discounts that they promised and is financially motivated to do so.
• Terms and Termination Provisions – what appears to be “standard language” may not be. Position yourself for long-term success with built-in rate guarantees and termination language.
• Pharmacy Review – create full transparency of your pharmacy product, including Rx rebates.
• Fees and Services – there are many fees and caveats that can clutter up your financial arrangement and cost you more.
• Claims Audit Parameters – negotiate an “audit friendly” contract to ensure you can achieve a statistically valid audit as frequently as you’d like.
• Claim Edits – make sure your carrier is handling decisions regarding your money as efficiently as they do their own.
• Manual Claim Audits – help prevent large dollar auto-adjudication errors by requesting manual claim audits.
• Credit Balance Audits – be certain that the facilities that receive your money in error are giving it back in a timely fashion. 

Annual Estimated Savings:  2-3%

Part 4  The Stop Loss Formula 

A properly structured stop loss program can save you 1% - 2% on your annual healthcare spend. This analysis will compare your current stop loss coverage and rates with expected values based on Milliman’s databases and industry information. Milliman will benchmark your current arrangement to industry averages and to the ACBG model. Your specific stop loss attachment point determines the amount of risk that your company takes and the amount of premium you pay for stop loss coverage. This analysis will illustrate for you a variety of different stop loss attachment points and show the resulting impact on risk and cost. Annual Estimated Savings:  1-2%

Part 5  The Performance Snapshot 

An effective employee Health and Productivity Management Program will increase your employees’ productivity and lower their absenteeism, workers compensation claims and medical and pharmacy claims.

You will be provided performance benchmarking through our partnerships with the University of Michigan Health Management Research Center (HMRC) and The National Business Group on Health. The National Business Group on Health has established a set of standardized metrics and benchmarking tools to help you evaluate the health and productivity of your employees. The Performance Snapshot enables you to participate in meaningful benchmarking, to evaluate your benefit plan performance, and to gain access to decision-support tools. Annual Estimated Savings: Peace of Mind

Part 6  The Claims Projector 

Milliman will provide you with a projection of the next five years of your expected medical and pharmacy claims assuming no changes to your current setup. Next, Milliman will compare your current setup to an alternative scenario that would be representative of care delivery under ACBG.  

All progress begins with the truth.  Knowing where you are going will help you determine how to manage your healthcare costs going forward. Annual Estimated Savings: Clarity and Confidence

Part 7  The Champion Company Solution 

Over the last 30 years, the HMRC has scientifically proven that an individual’s cost spend on healthcare is directly related to their health risk factors (i.e. cholesterol, blood pressure, body weight, alcohol, etc.). Their research has also shown that you will reduce healthcare costs by reducing your health risk factors. The HMRC will provide you with a Medical Economics Report that estimates your company’s health risk status and potential cost savings resulting from an introduction of a comprehensive health management program.  

You will also learn what a healthy low-risk individual is costing your health plan as compared to medium and high risk individuals. This difference in cost is considered the excess amount you are paying for individuals that are at a higher risk level. You will then learn how you will save money by helping people move from higher risk categories to lower risk categories.  

Using your actual data, HMRC will prepare a multi-year cost projection assuming you maintain your current level of health and wellness promotion engagement. Secondly, your current program will be compared to three best-in-class levels of health promotion programs. Annual Estimated Savings: 5% growing to 20% plus