Is Your Health Plan a Victim of Pharmacide?

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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!

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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!

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Bringing Forward Thinking and Transparency to Employee Benefits

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Diversified Group continues its efforts to bring a revolutionary perspective and innovation to employee healthcare. With the recent launch of our monthly email newsletter, Healthcare Uncensored, we are attempting to break down the walls of healthcare complexity and shed light on the confusing state of employee health benefits. Each issue addresses and openly discusses a particular trend or pressing issue that is having great impact on employers and plan members.

“Real change in the world of health benefits won’t happen unless everyone – employers, brokers, providers and consumers – gets involved,” said Brooks Goodison, President of Diversified Group.

By encouraging all to join the conversation and asking questions most are afraid to address, we are paving the way for true healthcare transparency and trying to provide real solutions to the employee benefit concerns of many.

We are proud to say that our efforts are not going unnoticed. Earlier this month, Diversified Group was recognized by The Phia Group with the 2018 Empowered Plans Award at its annual MVP (Most Valuable Partners) event. “We analyzed all of our MVPs based on a number of parameters including, but not limited to, collaboration with The Phia Group, beta testing, using of services and products, a willingness to innovate and take risks, a forward-thinking methodology and efforts taken to secure the future of our industry. When we finished our calculations, Diversified Group was a clear winner.” stated Adam Russo, CEO of The Phia Group.

“We are very honored to have earned this recognition from The Phia Group. Empowering plans is the core value we bring to our customers seeking effective alternatives to the traditional carrier based ASO and fully insured plans – the market is hungry for empowerment,” stated Brooks Goodison in response to the announcement.

Furthermore, The Phia Group recently interviewed Brooks Goodison as part of their “Empowering Plans: Best of the Best – Sitting Down with an MVP amongst MVPs” Podcast. This was part of The Phia Group’s “Partners in Empowerment” series. In the episode, which is now available on YouTube, Brooks discusses the industry at large, the appeal as well as the challenges and what makes Diversified Group different than the typical Third Party Administrator.

Diversified Group is honored to see our cutting-edge focus and commitment to full transparency gaining recognition within the self-funded community.

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Commonsense Reporting Bill Introduced

dg-commonsense-reportingIn October, a bipartisan group of senators introduced a bill that would ease the ACA reporting mandates for employer-sponsored health plans. The bill would roll back the reporting requirements of Section 6056 and replace them with a voluntary reporting system. The bill would also allow payers to transmit employee notices electronically rather than having to send paper statements by mail.

While self-funded health plans must now comply with Sections 6055 and 6056, it is not yet clear how the bill would affect Section 6055 requirements. Senators Rob Portman of Ohio and Mark Warner of Virginia, sponsors of the bill, say their proposal would give the government a more effective way of applying premium tax credits to consumers who purchase insurance through an Exchange, something the administration has been trying to accomplish.

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Responding to Growing Demand for Transparency

Experts agree that a lack of true price transparency has contributed significantly to the inefficiency in healthcare. Several websites compare the costs for certain procedures at varying hospitals, but it’s still very difficult, if not impossible, to make an informed choice when preparing for a non-emergency procedure. As a result, most people still go to doctors participating in a covered network and follow physician referrals when a specialist is required. In most cases, these choices are made without any knowledge of the cost.

Powerful Mobile Technology

Today, leading TPAs are providing self-funded health plan members with a variety of very powerful mobile transparency tools. One new mobile app enables members to identify fair pricing for more than 200 common procedures, including surgeries, imaging and diagnostic testing. By linking a rewards program, the app awards financial incentives when high quality, competitively priced providers are selected over those with lesser ratings.

Another software maker that describes a third of healthcare procedures as “shoppable”, has introduced a mobile app that enables plan members to search for physicians by procedure, location and price. This tool even goes beyond facts and figures to provide detailed descriptions of the procedure being searched. When members need further assistance, care navigators are available to provide online support via a live chat option.

Expert Administration Still Matters

While a totally open pricing system may never be possible in a business as complex as healthcare, TPAs are making self-funded health plans more transparent all the time. Strategies such as Reference Based Pricing and Concierge Health Advocacy are having a tremendous impact on cost and employee engagement. And while insurance carriers typically withhold claims data from fully insured groups, TPAs are experts at helping their clients put valuable claims data to work to identify cost drivers and manage chronic conditions in ways that help the plan avoid catastrophic claims in the future.

As the transition from volume to value-based healthcare continues, more responsibility will land in the hands of plan members. Smart employers know that a well-designed health plan can foster positive change and lower costs only if members understand their benefits. As long as self-funded plans, highly personal service and creative ideas are allowed to flourish, the number of engaged consumers capable of making economically wise healthcare decisions will continue to grow.

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Self-Funded Healthcare – A Great Option for 2017

Diversified Group believes that self-funded plans are the most cost effective and transparent health insurance option for most companies. Not only have we been administering self-insured health plans for 50 years, we have a self-funded medical plan for our organization. As a third party administrator (TPA), we provide comprehensive and cost effective solutions that help employers control their healthcare costs.

The article below discusses the reasons why large companies, as well as an increasing number of small- and mid-sized companies, have switched or are considering a switch to a self-funded healthcare plan. The article also highlights the advantages of partnering with an independent TPA, such as Diversified Group. We design, manage and administer customized benefit plans that employers and their plan members can feel good about. As a Diversified client, you will receive the data and guidance to control plan expenses and create the opportunity for savings. Plan members have financial protection, quality benefits and information they can understand. If you’re looking to gain more financial control over your group health plan, read below and contact us to find out how we can help get you started!

The article below is from Employee Benefit News, titled “Why self-funded healthcare is a great option for 2017,” by Paul Johnson.

Small- and mid-sized companies using traditional major medical plans are at a competitive disadvantage: either they are paying more in loaded costs than competitors that use smarter healthcare options, or they are finding it more difficult to hire employees because their competitors offer better plans.

With the new year and a new healthcare landscape, HR executives and benefits directors are now reconsidering their options, taking a much harder look at out how they can stop struggling to offer competitive benefits, and actually use their healthcare plans to recruit and retain the best talent, which will ultimately boost employee morale and profitability.

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Source: Kaiser Family Foundation/HRET, from www.benefitnews.com

Annual premiums for employer-sponsored family health coverage reached $18,142, with workers paying $5,277 toward their plan in 2016, according to the Kaiser Family Foundation.

While companies still shoulder the lion’s share, worker contributions increased about 80% over the last 10 years; this cost doesn’t even include the employee’s co-pay or deductible.

To balance the scales and create a competitive advantage, more companies are turning to healthcare plans based on a self-funding model that offer more flexibility, customization and cost-savings while still improving the quality of care. Self-funded plans have been almost universal among large employers for quite some time, yet only in recent years have more HR departments at small- and mid-sized companies started to realize the benefits. Continue reading

2016 ACA Transitional Reinsurance Form Deadline: November 15, 2016

dg-aca-transitiona-reinsurance-blogBeginning in 2014 and continuing through 2016, employers and other sponsors of self-funded health plans, as well as insurance companies offering insured health plan products are subject to the Affordable Care Act’s transitional reinsurance fee.

This fee was designed to fund reinsurance payments to health insurance issuers to cover high-risk individuals in the individual market. The transitional reinsurance payments are intended to stabilize insurance premiums in the individual market during 2014, 2015 and 2016 as consumers and insurers become more comfortable with the state health insurance exchanges.

Although all contributing entities are responsible for the reinsurance contribution, they may use a TPA contractor to support the reinsurance contribution process.

How Does a Contributing Entity Make Reinsurance Contributions?

Contributing entities (or TPAs on their behalf) are required to register on Pay.gov in order to complete the contribution process. Using Pay.gov, the contributing entity will access the “2016 Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form” to enter the annual enrollment count. Additionally, contributing entities will schedule payment for calculated reinsurance contributions on the payment page. Continue reading