Self Funded Medical Insurance Cost Containment Strategies

We lower healthcare spending, by lowering the cost of care.

We are benefit plan advisers strictly focused on decreasing healthcare spend — without having to change your current plan design or shift cost to employees.

Why does your healthcare cost continue to rise?

There are many more reasons than what we have outlined here, but this list is a good start.

Government defined medical loss ratio

The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care. This mandated spend actually give the carriers no real reason to control your insurance claims. Higher claims means greater profits.

Broker trips and persistency bonus.

Would it shock you to believe that insurance carriers have incentivized consultants with huge bonuses and give away personal trips for what the industry calls “persistency”. This means that your best interest are put at jeopardy by a perverse incentive that encourages you to renew with that carrier.

Poorly written plan documents

When plan documents, stop-loss policies, networks, employee handbooks, and service agreements fail to align, claims go unpaid and nancial ruin is a real possibility. This clearly leads to significant and unnecessary risks.

Commission based compensation

Brokers, especially the publicly traded ones, have a massive incentive and shareholder responsibility to raise revenue. If their compensation is directly tied to your health insurance premium, how can their goals be aligned with yours?

Preferred Provider Organization (PPOs)

Preferred Provider Organization networks charge access fees, a fixed cost of a group health plan, of $12 – $20 per employee per month for what is arguably the obligation to overpay providers for healthcare services. This leads to a failure in your companies fiduciary responsibility under ERISA.

Outrageous pharmaceutical spending

Do you know if there is a spread between the pharmacy and your PBM contract? Do you have any mechanism in place to know if your overpaying for prescriptions? The unregulated greed, price spikes, formulary changes, differential contracting and more lead to a substantial increase in prescription cost for year to year.

Little to no transparency or oversight

The majority of medical insurance carriers make it tough to access real claims data. Far too many medical claims are auto-adjudicated based on a UB form, which allows for billing errors a manual review would have caught.

Little to no access to quality metrics.

Not only is healthcare cost opaque, but so are the quality metrics of the doctors and hospitals. This gives members almost no chance to make good decisions about who will treat them. Simply paying more for health insurance doesn’t make it better, it just makes it more expense.

Orthopedic and musculoskeletal management

Orthopedic and musculoskeletal claims can make up a massive part of your health plan spend. There are big differences in the cost of these services. Left unchecked, these cost of these can bust a plan quickly.

How do we view your health plan?

Often times we become trapped in a “there is no better
way” mindset. Let us show you a better way.

We often suggest that a CFO should look at their health plan ID card as an unlimited, unchecked, and auto-paid corporate credit card. When your employee tun in corporate expenses, what check and balances do you have in place? Do you pay whatever expense they turn in without scrutiny? Do you think the same scrutiny is applied when that same employee uses the health plan?


Right now you trust a small internal team to set rules around what, where and how employees can spend company funds. When we look at your healthcare spend; common sense and ERISA demand the same level of corporate oversight. Smart controls, a well thought out strategy and other cost containment tools can result in better care and better outcomes for your employees, while significantly lowering costs for all.

…so how can we decrease the actual cost of care?

We deliver a different message focused on long-term cost containment, transparency
and breaking free of the 12 month “quote and hope for results” cycle.

Measure what you wish to control

According to studies performed by the U.S. Government and Equifax, over 90% of all hospital bills contain errors, to the detriment of the payer. Our audits reveal mistakes that average 7.15% in savings with a 5 year track record.

Out-of-network management

Out-of-network charges can get out of control quick. We implement policies that drastically reduce the out-of-network claims process that will substantially reduce your claims spend.

Performance based compensation

Chances are you are currently paying your broker for activity instead of outcome. We base our compensation on how well the health plan performs, instead of how much you pay in premium.

Prescription benefit risk management

If you spend more on prescription medications this year than last, we can reverse that trend. We have see plan participants save 20% – 50% on average in the first 12-18 months with no changes to benefit design.

Direct contracts

A nationwide, all inclusive network of directly contracted providers. Covering hundreds of procedures and services ranging from lab to imaging to surgery at an average of 61% off national average.

Catastrophic claims management

Strategically designed cost saving program for high ticket medical claims. Including diseases like dialysis, cancer, hemophilia, hepatitis C, chron’s disease, colitis and transplants.

Direct primary care

Personalized, comprehensive healthcare, available to you and your employees. Access to same day appointments with on-site or near site clinics. DPC puts the relationship back in the doctor-patient relationship.

Alternative claim pricing

Employers are driving a trend toward alternative medical cost management seeking reprieve from inflated medical pricing and PPO overpayment — this can result in significant plan savings.

Better choices at renewal

Forget shopping just a few carriers at renewal. Does your broker show you level-funded, self-funded or captive solutions at renewal? Have they even talked about those options?

Can we prove any of this?

You bet we can, here are a few ways…

Medical bill review & recovery

A two year audit of past claims will allow us to identify potential recovery opportunities for any unwarranted charges on a contingency basis. More importantly, it will allow for additional savings by using the same process for future claims. Your savings opportunities can typically be anywhere between 4% – 7% of total claims spend.

Direct contracts benchmarking

We benchmark what you paid over the last 12 months for over 145 procedures like orthopedics, general surgery, colonoscopies and even some imaging, against our direct contracts. Then we deliver to you a complete cost, risk & quality analysis. On average you can expect to see $250k in savings per 1,000 enrolled employees.

Pharmacy Benefit Analysis

Similarly to the direct contracts benchmarking, our team can take your historical prescription data and preforms a pill-for-pill repricing. We take this even further by taping into our proprietary  formulary that has over 450+ prescriptions at 50% – 90% off retail. This can result in a 20% – 50% reduction in prescription spend.

“Break free from the 12-month quote and hope cycle” with Workforce.

How else do can we help?

Enterprise Grade HCM

As an option addition, we offer an integrated payroll, time, scheduling & tax engine that simplifies your entire employee lifecycle. Our enterprise HCM solution automates business process while ensuring accuracy and providing in-depth reporting options.

New Hire & Open Enrollment Support

We employ a comprehensive multi stage approach when conducting enrollments. The process begins several months before enrollment begins and carries on after it is completed. We customize this process to align with your initiatives and business goals.

Compliance Support

Through our partner company, we offer a comprehensive consulting services, legal expertise, plan document drafting, subrogation and overpayment recovery, claim negotiation, and plan defense designed to control costs and protect plan assets.


We want to learn more about you! This short call gives you time to let us know about your needs to see if our product is right for you.