Ever Asked a Hospital What a Procedure Costs Them?

dgb-hospital-room

Can the cost of a hip replacement in Philadelphia really vary from $11,000 to $125,000?

From white papers to published books, much has been written about how difficult it can be to find out what a hospital stay or outpatient procedure will cost. And as Anna Wilde Mathews observed in her article Lifting the Veil on Pricing for Health Care, the mystery surrounding healthcare pricing stems partly from the fact that hospitals and other providers generally don’t publicize how much they’re paid for services, which varies depending on who’s footing the bill.

Much has changed recently. And while it is difficult for websites like healthcarebluebook.com to quote exact pricing, they do suggest what a reasonable price should be based on what insurance carriers have paid hospitals for certain procedures in a certain geographic region.

It’s easy to understand why hospitals are reluctant to share price information. Consider the results of a study on hip replacement surgery published by JAMA Internal Medicine. According to Dr. Joseph Bernstein, professor of orthopedic surgery at the University of Pennsylvania, while more than half of the 120 hospitals surveyed could not provide a cost for the surgery, those that did quoted prices ranging from $11,000 to $125,000.

How can your health plan achieve price and quality transparency? Treat healthcare expenses like other business expenses! Self-fund with Medicare Reference Based Pricing and partner with a TPA that has the willingness and know-how to hold providers accountable.

These are today’s keys. These are the things we do for our clients each and every day. To take control of your healthcare costs, give us a call at your convenience.

Tell Us How You Feel!

dg-healthcare-uncensored

Is Your Health Plan a Victim of Pharmacide?

pharmacide

Over the past several months, the Trump administration has introduced several ideas intended to fight skyrocketing prescription drug prices – everything from forcing manufacturers to display prices in their television commercials to having Medicare base payments for costly drugs on average prices in other industrialized nations, which are much lower than in the U.S.

While some prefer to criticize or sit silently by as prices keep rising, we say keep the ideas coming. This is a crisis requiring aggressive action, like our Pharmasense program, that tackles the real problems driving the cost of specialty drugs used to treat complex medical conditions.

Prior Authorization (Pre-Certification) is at the core of Pharmasense. It helps self-funded health plans avoid potential conflicts of interest that enable massive mark-ups and other abuses go unchecked. Pre-certifying specialty drug prescriptions prevents hospitals or PBMs from reviewing authorizations and dispensing specialty drugs without any independent review process. The same is true when providers submit specialty drug prescriptions as claims under the medical plan rather than the prescription drug benefit plan. As an independent TPA, we use these tools to deliver quality patient outcomes and significant cost savings by avoiding the kinds of conflicts described above.

If your prescription drug costs are spiraling out of control, it’s time to take serious action. Talk to us about ways to prevent Pharmacide today!

Tell Us How You Feel!

dg-healthcare-uncensored

Are Your Plan Members Sharing in Your Plan Savings?

A little skin in the game can make a big difference.

At our recent “Let’s Take Control” themed Solutions Day, Adam Russo of the Phia Group shared his story that earned front page coverage in the Boston Globe. He told the audience about a tactic Diversified Group has helped many employer groups implement over the years – sharing plan savings with employees who are willing to shop for high quality, lower cost providers.

As Adam illustrated, employees of Phia Group who do their part to lower costs receive 20% of the plan savings. A member who saves the plan $5,000 on the cost of an MRI receives $1,000. And that’s just one example – their plan places no limit on the amount of savings it will give back to a covered member.

Diversified helps many self-funded employer groups craft their plan document to include member incentives. Waiving copays on generic drugs and urgent care visits is an easy option to implement. Another powerful step is to reward plan members who speak with HR before arranging for a costly healthcare procedure such as surgery. Not only will this engage members and open their eyes to available savings, but it can often create an opportunity to better manage or perhaps even avoid a large claim in the future.

Incentivizing members is just one of the ways we’re helping employers “take control” of rising healthcare costs. To learn more about this and other solutions made possible by self-funding, give us a call at your convenience.

Tell Us How You Feel!

dg-healthcare-uncensored

Who Are All the Stakeholders Really Looking out For?

dgb-hcu-trust

Controlling Health Plan Costs Is Everyone’s Responsibility

Recent trade publication articles have featured tales of large carriers offering bonuses and quarterly incentives to advisors who agree to move their clients from a self-funded health plan to fully-insured.

After managing self-funded health plans for more than 50 years, we’ve seen just about every scheme you can think of. And while we believe in marketing as much as the next guy, we place a far greater priority on accountability.

When we help an employer self-fund their health plan, we unbundle the component parts in order to design a plan that meets the client’s specific needs. There are no “one size fits all” solutions. From broker to stop loss carrier, PBM to nurse navigators, it takes a dedicated team of experts to achieve our client’s goals and objectives.

To develop a winning team, we partner with brokers, advisors and vendors who are not only experts in their field – they share our commitment to cost transparency and accountability.

While others may be willing to work with stakeholders who consider huge claims and annual premium increases as status quo, we’ll continue to partner with those who are dedicated to delivering the best possible outcomes for plan members at the lowest possible cost. Because when our clients succeed, we succeed. Period.

Tell Us How You Feel!

dg-healthcare-uncensored

Who Owns Your Claims Data?

stats on ipad

You Can’t Manage What You Don’t Measure!

With a self-funded healthcare plan and a good, independent TPA, access to claims data is standard operating procedure. Even more important, a good TPA like Diversified Group has the expertise to convert your data into intelligent, actionable strategies to manage your plan, monitor performance and modify plan design to control costs.

In contrast, employers with fully insured health plans seldom see their claims data. Even self-funded plans managed by large carrier-owned ASO divisions are often unable to receive claims data on a regular basis.

Analyzing claims data with state-of-the-art tools helps identify, analyze and manage potentially high dollar claims. This capability alone saves many of our clients more than 20% annually. Hospital stays can be monitored, claim costs can be unbundled to detect fraud and abuse and discounts can be negotiated without compromising the quality of care received. Even the rising cost of specialty (bio-tech) pharmaceuticals can be managed when risks are identified early on.

If you’re not receiving claims data and analysis, you’re operating in the dark and it’s time you had a conversation with your broker or TPA. After self-funding your health plan, we consider analyzing claims data to be “Cost Control 101”!

Tell Us How You Feel!

dg-healthcare-uncensored

How Much Is Fraud & Abuse Costing Your Health Plan?

newspaper-headlinesFrom a drug manufacturer that contributes money to a non-profit Copay Assistance foundation and then steers Medicare patients taking their drugs to that foundation to a diagnostic lab that pays doctors for every blood test they refer, disguising the payments as “processing and handling fees”, there seems to be no end to the costly schemes plaguing our healthcare system. What is an employer group to do?

For starters, use partial self-funding to provide health benefits to your workers – even if your group is small. It’s the only way to know where your health plan dollars are going from month to month and year to year. Choose an independent TPA to design your plan, manage costs and advocate for your members. This way, you and your plan will have a dedicated, experienced team looking out for your best interests, rather than those of a provider or a large health plan (who may both be part of the same organization).

We can’t keep fraud and abuse out of the healthcare system. But by paying claims in strict accordance with your plan document, providing special handling for members with a serious condition or chronic illness, and helping your members choose high quality, high value providers, we can do everything in our power to keep it from impacting your health plan directly.

Tell Us How You Feel!

dg-healthcare-uncensored

Is Value Based Pricing Here to Stay?

value-based-pricing-hcu-email

With More Families Forced to Choose Between Healthcare & Housing, It May Be the Future

As a TPA, employer groups count on us to make their health benefits work. While that sounds easy enough, it can be anything but easy when ordinary working families face hospital bills they can’t handle.

One couple recently found themselves confronted by a hospital that rejected their coverage, demanding an advance payment of $9,000 for their child’s tonsillectomy, with a $10,000 balance due following the procedure. Because the employer has replaced their PPO network with Value Based Pricing (VBP), we were able to work with the parents, their regular pediatrician and ELAP Services to arrange for the procedure to be performed at a local, affiliated surgical center. Their total cost was less than $2,000 – a fraction of the original price.

While a great deal of work and cooperation were required to achieve this outcome, Value Based Pricing made it possible, by defining pricing limits in advance and encouraging dialogue between the patient, the provider and us as the TPA.

In a time when too many hardworking Americans are facing extraordinarily difficult healthcare decisions, helping employers and hospitals agree on pricing schedules for covered benefits may be the only way to keep quality healthcare within reach for small and mid-sized employers and the workers they depend on.

Tell Us How You Feel!

dg-healthcare-uncensored