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Mike Adams & Scott Conard on The Vital Importance and Role of Your Broker

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Running Your Second Business – Your Health Benefits Broker Relationships in Healthcare Benefits Planning: Transparency, Innovation, and the Real Value of Partnership In planning healthcare benefits having the right broker may be the most essential yet often overlooked relationship. Brokers are the gatekeepers, guiding organizations through the complex landscape of legal, compliance, and marketplace options. But not all broker relationships are created equal, and there’s a lot to consider when determining the true value of a broker. Reclaiming Strategic Control: Brokers as Partners, Not Planners For any business leader, it’s crucial to treat brokers as consulting partners rather than as strategic decision-makers. Your company’s vision, values, and goals should shape your benefits strategy—not your broker’s latest product lineup. While brokers bring industry insights and can be invaluable for vetting and implementation, they shouldn’t be your main source of innovation. The best approach is to take ownership of the strategic direction. Tap into other resources—conferences, peer networks, and industry research—to identify trends and innovations. Then, involve your broker as an implementation partner. Share your ideas and ask them to stress-test these solutions: How would this integrate into our current benefits ecosystem? What data would we need to make this work? Where are the potential pitfalls? This approach ensures that brokers act as allies in achieving your strategic goals rather than dictating them. When you lead the innovation, your broker’s role becomes one of enabling and refining rather than steering. The Problem with Kickbacks and Hidden Agendas One of the most troubling issues in broker relationships is the lack of transparency around compensation structures. In many cases, brokers earn commissions or “back-end” deals through point solutions, which can create conflicts of interest. These financial incentives often go unreported, leaving employers in the dark about whether a recommendation truly serves their needs or merely boosts the broker’s earnings. The reality is, when 80% of corporations say they rely on their broker’s advice for benefits planning, there’s an inherent risk that these hidden incentives will skew decision-making. Employers need to understand that without full disclosure, they may be getting a recommendation driven by profit rather than by what’s best for their organization and employees. Demanding Transparency in Broker Compensation Transparency in broker compensation is non-negotiable. A company has the right to know exactly how a broker is compensated, whether through commissions, retainers, or equity stakes in recommended products. Clear, upfront agreements—such as a flat fee for specific services—builds trust and is the best way to avoid any perception of bias. Some employers limit broker commissions to only a handful of services—like medical, dental, and disability insurance—while establishing strict controls around fees for point solutions. This approach minimizes conflicts of interest and helps ensure that every recommendation aligns with your organization’s needs. Why Transparent, Value-Driven Broker Relationships Matter At the end of the day, a transparent and well-aligned broker relationship directly impacts the quality of benefits you provide to your employees. Quality benefits aren’t just about saving money; they’re about enhancing the quality of care for employees. By reducing unnecessary costs and improving care, both the employer and employees win. When companies hold brokers accountable, they not only save costs but also create a benefits ecosystem that genuinely supports their workforce. In healthcare benefits planning, transparency, proactive partnership, and a commitment to quality over quick fixes make all the difference. Written by Rob Thwaites.

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Moving from Fee for Service to Prospective Payment in Primary Care:

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Advanced Primary Care: The Future of Primary Care Part 1 Sponsored by www.ConvergingHealth.com This series of blog posts will provide a detailed description of a model for primary care service delivery that we call Advanced Primary Care. Why Advanced? Because it takes the core principles and practices of whole-person primary care and transforms them into a proactive process that will improve the health of individual patients, especially the most vulnerable, and the population served by a primary care practice. We believe, and evidence supports, that moving from a Fee-for-service payment model to a prospective payment model, especially when it involves full financial risk to the practice, requires a new way of thinking about patients and patient care delivery. 1) Why is there a need to transform primary care practices from the traditional RVU/fee-for-service model to a capitated/prospective payment Advanced Primary Care model? The RVU/FFS model does not incentivize improving the health of the individual or the population. The incentives drive more utilization to capture more revenue for the individual physician, their practice and/or the organization for whom they work. It rewards the wrong behavior. Said another way, because it’s killing patients with over and under treatment. It’s killing caregiver morale. The financial toxicity is bankrupting the people it is supposed to be serving, and it’s undermining the mission and practice of primary care. It’s got to be restructured in a way that the stakeholders are aligned and pulling in the direction of better health and well-being of the patient. We’ve become high paid insurance coders and we need to get back to being healers. We do a lot more than generate codes for the insurance company to justify our work. Today’s system needs to be replaced by one that is focused on better care, healthier people, and lower costs. With prospective payment, if practices care for patients using the model of care delivery they developed in the FFS paradigm, they will fail to realize their tremendous potential. Succeeding in prospective payment requires a shift in the paradigm to organize the docs, the staff, the clinical data used to prioritize the work being done in a clinically relevant way. In the FFS paradigm you get patients in and get them out in numbers, volume is the game. It is the core driver of financial viability. It’s not that you don’t try to offer the best care possible for each patient, you do. However, if the patient gets better or their health improves, you actually lose revenue. If the patient ends up in an urgi-care center or the ER or if they decide to see a specialist in FFS, the system wins financially. With prospective payment, the PCP loses clinically and financially. The FFS model rewards reactive, short-term problem solving not proactive health improvement and engagement with a patient. In FFS the staff works to move the patients from front office to the exam room and out the door as fast as possible, maximizing physician billing and coding. They are not proactively building and participating in carrying out the care plan. The whole medical team is not collaborating and do not appreciate the greater role each member could play when they use all of their skills to add to the comprehensiveness and continuity of care. Their energy is not actively contributing to the effort to increase the patient’s health literacy, the patients’ trust (loyalty) and the practice’s efforts to care for them. Patient confidence and loyalty is a big part of the long-term success in the prospective payment paradigm. Succeeding in the world of prospective payment requires what we call an Advanced Primary Care model wherein the docs/clinicians and the staff are closely aligned to identify and address the patient’s issues. With prospective payment and especially with full risk contracts, the practice is financially successful when the patients get healthier and they are working collaboratively with the practice. It incentivizes health and well-being, focuses the staff, and improves the effectiveness and efficiency of the delivery system. Scott Conard, MD Michael Tuggy, MD Susan Lindstrom Laurence Bauer, MSW, MEd [email protected] [email protected] [email protected] [email protected] Authors Scott Conard, MD FAAFP, DABFM Chief Medical Officer The National Alliance of Healthcare Purchasers Leadership Council The National Association of Worksite Health Centers Co-Founder & CEO Converging Health, LL [email protected] Michael Tuggy, MD, FAAFP Past President – AFMRD, founder of the Residency Curriculum Resource. Vice Chair – Family Medicine for America’s Health 2014-2019 Rural Family Physician and Medical Director for Health Plans and UM – Confluence Health Clinical Professor, University of Washington School of Medicine [email protected] Susan Lindstrom President, Converging Health, LLC Susan Lindstrom has been working as a My Personal Health Assistant at Converging Health for 4+ years. [email protected] www.mypha.com Laurence Mahoney Bauer, MSW, MEd Mr. Bauer was the founding Chief Executive Officer of the Family Medicine Education Consortium (www.fmec.net) a position he held for 27 years before his recent step down from leadership. He has served as faculty member at three medical schools and as a consultant/advisor to many other medical organizations. He has been an active supporter of Family Medicine and primary care since 1978 when he began his work in medicine. He believes the nation needs a primary care-driven system. [email protected]

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The Vital Role of a Physician Executive: More than Just Healthcare Management with Mike Adams

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By Mike Adams and Scott Conard M.D. When we think about a physician, the classic image is someone in a white coat, caring for patients. But in today’s healthcare landscape, there’s a new kind of physician stepping into a very different role—one that’s shaping the way companies approach employee health benefits, healthcare costs, and workplace well-being. This is the physician executive, and they’re here to break traditional molds, offering insights that align medical expertise with business strategy. And the impact? It’s profound. A physician executive isn’t just a consultant ticking off metrics; they’re catalysts driving companies to ask the tough questions about healthcare. They’re the ones who help employers understand not only what health benefits to offer but why these decisions matter to both their people and their bottom line. Breaking the Benchmark Trap and Leading the Pack Let’s talk benchmarks—a favorite topic in the world of employee benefits. Many companies measure themselves against industry standards, but is being “average” really good enough? Physician executives challenge this mindset. They encourage companies to stop aiming to be in the middle of the pack and instead set new standards that prioritize quality care and employee well-being. One popular saying captures their philosophy perfectly: “Lead, follow, or get out of the way.” That’s the attitude physician executives bring to the table. They aren’t there to rubber-stamp the same-old solutions. Instead, they push companies to take an innovative approach, whether it’s in healthcare plan design, employee engagement strategies, or even how they measure success. The goal is to create a benefits package that’s not just comparable, but truly better—one that resonates with employees and delivers real results in terms of health outcomes and cost savings. Aligning Employee Experience with Quality Care Here’s a crucial insight from the physician executive’s perspective: employee experience doesn’t just mean giving employees everything they ask for. Rather, it’s about designing healthcare benefits that balance experience with top-notch clinical care. The focus should be on creating an environment where employees are engaged, healthy, and supported, not just momentarily satisfied. This is where a physician executive’s clinical insight comes in. They’ve spent time in the trenches, navigating the patient care process, so they understand firsthand what high-quality care looks like and how to deliver it efficiently. They know how to blend the “wants” with the “needs” to create benefits that improve employees’ overall health and productivity. The Converging Health Solution: Data-Driven Savings and Better Outcomes If you’re a company leader looking to improve your healthcare strategy without breaking the bank, consider partnering with Converging Health. Physician executives from Converging Health specialize in using data to guide smarter healthcare choices, helping businesses focus on what really matters. With a deep understanding of behavioral economics and healthcare systems, they know where to trim costs without sacrificing quality. Converging Health’s services, grounded in analytics and a comprehensive understanding of the healthcare ecosystem, help companies manage complex healthcare dynamics, from insurance to point solutions. They offer a blend of clinical expertise and financial insight that lets you see tangible savings—reducing unnecessary spending while boosting employee health and engagement. In short, with a physician executive from Converging Health, you’re not just navigating the system; you’re setting a new standard for healthcare benefits. Ready to save money and elevate care? Reach out to Converging Health and see how an innovative approach to healthcare can benefit your company’s bottom line and keep your employees healthier, happier, and more productive. https://www.converginghealth.com/contact-us Written by Rob Thwaites

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Relentless Health Value: Episode 462 with Converging Health’s…

Today, Dr. Scott Conard discusses the evolution of his life’s work, focusing on his current collaboration with Mike Adams from 7-Eleven to support their plan members. Their efforts revolve around a few striking yet common insights that many plan sponsors will recognize in their own data. One key finding: roughly 70% of individuals who exceed a plan’s high-cost threshold in any given year were previously high-risk but low-cost. These individuals don’t appear out of nowhere—they were identifiable in prior years. The challenge is to identify them early and provide the right interventions to prevent them from transitioning into the high-risk, high-cost category. Effectively managing a population requires proactive identification of high-risk, low-cost members before they escalate into high-cost care. To achieve this, Dr. Conard follows a best-practice, stepwise approach, which we’ll outline below. While we cover each step in the discussion, some are explored in greater depth than others. Best-Practice Approach to Managing Population Health 1. Get the Data – The Whole-Person Risk Score Rather than categorizing members into isolated disease groups, the goal is to assess risk at a whole-person level. Patients aren’t just a collection of separate conditions—they’re complex human beings whose health factors interact. Dr. Conard often uses a car analogy: If a car’s tires wear out, you simply replace them. But humans don’t work that way. A patient may need surgery but be unable to proceed because their cardiovascular markers are too high. Yet, they can’t take the necessary medication due to contraindications with existing kidney or liver conditions. This fragmentation in care often leads to patients being bounced between specialists who don’t communicate effectively. A real-world example comes from Miriam Paramore, who shares a harrowing story about her father’s end-of-life care—an illustration of why whole-person risk scoring is critical. 2. Provide Access to Advanced Primary Care Teams Members need access to high-functioning primary care teams that are empowered to make informed referrals to top-tier specialists. These teams should ensure care is high-quality, appropriate, and optimized for each patient. 3. Align Benefit Design with Optimal Care Pathways Plan sponsors must structure benefits to support the care members need. If benefit design creates barriers—like high co-pays for essential services—members may forgo necessary care, leading to worse outcomes and higher costs in the long run. Dr. Mark Fendrick once compared benefit design and optimized medical care to peanut butter and jelly—they must go together. For example, if a doctor tells a diabetic patient to get regular foot exams to prevent amputations, but the patient can’t afford the co-pay, the system fails. The patient suffers, the doctor’s quality scores take a hit, and the plan sponsor ultimately pays for costly, avoidable complications. Step 3 ensures benefit design supports, rather than hinders, effective care. 4. Engage Members with Navigation Tools Members need guidance to navigate the healthcare system effectively. Tools like My Personal Health Assistant play a crucial role in engaging unengaged patients and ensuring they follow optimal care pathways. These tools complement advanced primary care efforts, helping members stay on track and receive the right care at the right time. By following this structured approach, plan sponsors can proactively manage population health, reduce costs, and improve outcomes—transforming their approach from reactive to strategic.

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HR Director’s Dilemma: How Corporate Financial Incentives Impact Employee Healthcare Costs and Access

Employer Healthcare Solutions / Converging Health Website

As an HR director, managing employee benefits is one of the most impactful ways to support your workforce. Yet, navigating the complexities of healthcare costs and access has never been more challenging. Corporate financial incentives—the unseen forces behind many decisions in the healthcare system—play a critical role in shaping the quality and affordability of care for your employees. These incentives, while often intended to improve efficiency, can unintentionally lead to higher costs, reduced access, and a focus on profit over patient outcomes. Understanding how these financial incentives affect your employees’ healthcare experience is essential. Here’s a breakdown of key factors and potential solutions: Employer-Sponsored Health Plans: Navigating the Balancing Act Provider Incentives: A Double-Edged Sword Pharmacy Benefit Managers (PBMs): Misaligned Incentives Insurance Companies: Limited Competition, Rising Costs Lack of Transparency: A Barrier to Better Decisions The Ripple Effect on Employees and the Economy Charting a Path Forward: Solutions for HR Leaders A Call to Action As HR leaders, we have a unique opportunity to influence not just the lives of our employees but the broader healthcare system. By understanding the unintended consequences of corporate financial incentives and advocating for innovative, patient-centered solutions, we can create a system that prioritizes care over costs. It’s time to step up, ask the tough questions, and champion changes that benefit our employees, organizations, and communities. Together, we can transform healthcare from a source of stress into a cornerstone of employee well-being and organizational success.

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Primary Care for All

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An initiative that will transform the U.S. health system so that it is driven by Advanced Primary Care by Scott Conard, MD There is a group of us who are working together to bring a foundation of advanced primary care to every American. With this foundation we can establish a “system” of care for America that will significantly reduce the confusion, disorganization, low health literacy, inappropriate navigation, and excess costs. At this time our initiatives are:To Renew the commitment to a primary care system: Create a renewal process that will stimulate deep reflection that leads to re-discovery and embrace of the core values, goals and sense of purpose that underlies the Family Medicine movement To Revitalize those believing in the value of advanced primary care: To inspire and to articulate a vision for the next stage that engages a community of innovators and early adopters who will act on the vision. To Transform the system: To advocate and act on systems change: from models to networks to systems to institutions. All of this is based upon primary care that makes a difference. Running patients through 40/day, handing out referrals and scripts at a record rate, at 7 minutes a visit or spending an hour with every patient, ordering every possible test – regardless of evidence base and/or pre-test probability. Nor is it about ignoring what is going out outside of the office and just caring for those who call and make an appointment. Advanced primary care calls us to provide a higher level of service and care. Truly in the old “Marcus Welby” vision of caring for people as they age – having a trusted relationship – and ensuring patients get the right care, at the right time, in the right place, and at the right cost. What are your thoughts about this? Is it realistic? Is it fair to ask primary care providers to do more without providing better tools, better data and information, proactive reimbursement, or other support?

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We Are Healers

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We did not go into medicine to survive in a system of computer/paper work, administrative hassle, financial struggles, or corporate employee gamesmanship. by Scott Conard M.D. We are healers, and we make a tremendous difference in our patients lives. But misaligned incentives, the industrialization of medicine, legal and administrative burdens, and the perceived lack of value of primary care is creating a situation where surviving has replaced thriving. Our patients, the corporations they work for, and the US need us to get back to our purpose. The healthcare system must be built on a foundation of high quality, advanced primary care – and those delivering it must thrive, not just survive. This transformation begins with primary care providers investing in themselves and becoming the influential forces they can be. Working together, standing for themselves and their patients, with a clear and articulate message, we will make a stand for our value, the health and well being of our patients, and the success of our practices. If you are in primary care and are ready for change, then come reconnect with why you went into medicine, reconnect with the excitement and satisfaction you imagined, and become the leader in your lives, practices, community, and maybe the nation for the primary care system that will serve you, your patients, our corporations, and the country. Read more: https://themdceo.com/we-are-healers/

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The Hidden Cost of Overutilization and Lack of Primary Care: A Call to Action for CFOs and HR Directors

Employer Healthcare Solutions / Converging Health Website

As leaders responsible for balancing the financial health of your organizations with the well-being of your employees, you face a complex challenge: managing escalating health insurance costs without compromising the quality of care. Two often-overlooked factors significantly driving these costs are the overutilization of medical services and a lack of primary care engagement among employees. Overutilization of Medical Services: Paying More for Less Overutilization occurs when medical services are provided with a higher volume or cost than is appropriate. This includes unnecessary tests, redundant procedures, and avoidable emergency room visits. While these services may seem beneficial on the surface, they often do not contribute to better health outcomes and can, in fact, expose patients to unnecessary risks. For example, an employee with a minor headache might receive an expensive MRI scan when rest and over-the-counter medication would suffice. Such instances not only inflate individual claims but also contribute to higher premiums for the entire organization. Overutilization can account for up to 30% of healthcare spending, a staggering figure that directly impacts your bottom line. The Role of Primary Care: The First Line of Defense Primary care physicians (PCPs) serve as the gatekeepers of health, providing preventive services, managing chronic conditions, and coordinating specialist care. However, a significant number of employees lack a strong relationship with a PCP. This absence leads to fragmented care, delayed diagnoses, and increased reliance on specialist and emergency services—all of which are more costly and less efficient. Without primary care guidance, employees are more likely to self-refer to specialists for issues that could be managed by a PCP at a lower cost. They may also overlook preventive measures, resulting in advanced-stage diagnoses that require expensive interventions. The lack of primary care exacerbates overutilization by funneling employees into high-cost healthcare settings unnecessarily. Connecting the Dots: How These Issues Compound Costs The interplay between overutilization and lack of primary care creates a feedback loop that drives up healthcare expenses. Employees without primary care guidance are more susceptible to overutilization, and overutilization further discourages the establishment of primary care relationships due to the complexity and frustration it can cause. This cycle leads to: A Strategic Approach: Investing in Primary Care to Reduce Overutilization To address these challenges, consider implementing strategies that encourage primary care engagement and reduce unnecessary medical services: 1. Promote Primary Care Relationships: 2. Educate Employees: 3. Implement Value-Based Insurance Design: 4. Partner with Providers: Conclusion: A Call to Action As CFOs and HR directors, you have the opportunity to transform these challenges into strategic advantages. By fostering a culture that values primary care and actively combats overutilization, you can reduce healthcare spending while enhancing the well-being of your employees. Investing in primary care is not just a cost-saving measure; it’s a commitment to the long-term health of your workforce. It leads to better health outcomes, increased productivity, and a more sustainable financial model for your organization. It’s time to take a proactive stance. Let’s work together to build a healthcare ecosystem that delivers value, promotes health, and ensures that every dollar spent contributes meaningfully to the well-being of our employees and the vitality of our organizations. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

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Revolutionizing Population Health Risk Reduction: A Shift from Historical Costs to Root Causes

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

Written by Scott Conard, MD When it comes to population health risk reduction, the conversation is evolving. Historically, in the U.S., managing health costs has often been approached from an actuarial perspective—calculating insurance premiums based on past expenses and statistical projections. While this method has served its purpose, it focuses on trailing indicators like price per procedure and frequency of use, leaving the underlying drivers of healthcare costs largely unaddressed. But now, a shift is happening. We’re moving beyond simply accounting for costs to asking critical questions: What’s causing these costs to rise? What are the leading indicators that drive health risks and, ultimately, healthcare utilization? Moving Beyond Actuarial Science Traditional actuarial science calculates costs by factoring in variables like age, geographic location, medical diagnoses, and prescription usage. Insurers then project future costs based on past patterns, layering in adjustments for population demographics. While precise in its methodology, this approach is inherently backward-looking, focusing on how much was spent last year rather than proactively addressing what might reduce future spending. At its core, healthcare costs boil down to two key factors: price and use. But focusing solely on these metrics ignores a fundamental truth: the largest driver of healthcare cost is the risk of illness within a population. A high-risk population will inevitably lead to higher utilization and costs, while a low-risk population is significantly less expensive over time. Identifying and Addressing Health Risks To reduce health risks, we must first identify them. The answer lies in analyzing the population’s disease burden and the lifestyle factors driving it. Experience has shown that approximately 30% of a company’s population will eventually account for the majority of high-cost claims. More importantly, about 70% of those costly claims stem from conditions that could have been mitigated through early intervention and risk reduction. Lifestyle and Emotional Health: The First Line of DefenseMany of the conditions driving healthcare costs are preventable. Addressing lifestyle factors and emotional well-being plays a pivotal role in risk reduction. Strategies include: Navigating Healthcare Smarter The second pillar of health risk reduction involves empowering individuals to make smarter healthcare choices. This includes: High-Quality Care = Lower Costs A critical insight emerges when we focus on proactive health management: the highest-quality care is often the least expensive care. By identifying and addressing risks early, we not only improve health outcomes but also manage costs more effectively. Predictive analytics allow us to foresee who may require expensive treatments like surgery or dialysis, enabling timely interventions that are both effective and cost-efficient. The Future of Population Health This shift in focus—from trailing indicators like price and use to leading indicators like disease risk—represents a fundamental transformation in how we approach population health. By addressing the root causes of illness, promoting healthier lifestyles, and ensuring access to high-quality care, we can achieve significant reductions in healthcare costs while enhancing overall well-being. The path forward is clear: organizations must prioritize proactive health management strategies that address the underlying drivers of risk. By doing so, they can create healthier populations, reduce costs, and foster a more sustainable healthcare system. This isn’t just good for business—it’s essential for the future of healthcare. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

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Exposing Hidden Waste: Out-of-Network Payment Schemes

Employer Healthcare Solutions / Converging Health Website

Originally posted on choosewhichdoor.com/blog by Scott Conard MD and Brian Uhlig (Alera Group) As a senior executive, you’re constantly focused on efficiency, transparency, and maximizing the value of your company’s investments. Healthcare benefits—often one of your organization’s largest expenditures—should be no exception. Yet, many employers unknowingly bleed money due to hidden fees and opaque out-of-network payment arrangements. If you think a polished benefits package guarantees fairness and cost control, think again. Pulling Back the Curtain on Out-of-Network “Savings” ProgramsConsider a scenario: You have 5,000 employees. Your broker partners with a major carrier that promises a cutting-edge out-of-network cost-management program. On the surface, you’re shown impressive statistics: “We saved you X%!” “Your plan saved hundreds of thousands of dollars!” But ask a crucial question: Saved compared to what? Suddenly, the narrative isn’t so clear. One leading carrier’s program, One of the major insurance carriers offers out-of-network “payment integrity” solutions. The carrier presents data showing significant reductions in billed charges—numbers that look like heroic cost containment. Yet, behind these reported “savings,” the carrier often takes a percentage cut for themselves, effectively turning your plan’s supposed cost control measure into a revenue generator for the insurer. Real-World Example: The 13-Hour Office VisitImagine a provider billing over 50 increments of a single 15-minute service in one day—implying a marathon 13.5-hour visit. Under standard Medicare rates, this service might only be worth about $32 each time. Yet the provider’s billed amount was thousands of dollars, with the plan paying only a fraction. On paper, this program would claim massive “savings.” But in reality, the carrier charged the plan a hefty percentage of that “avoided” cost—far exceeding what the doctor actually received. In one particularly egregious case, the provider was paid a mere $61 while the insurer pocketed $3,700 in “fees.” The question executives must ask is: If the insurer knows these questionable billing practices are happening, why don’t they stop it? Quite simply, they profit from the difference. Where the Waste Happens—and How to Fix ItThis kind of wasteful spending arises when employers accept opaque arrangements without fully understanding the underlying payment mechanics. To address this problem, organizations must: 1. Renegotiate During RFPs:Start strong by establishing clear contract terms that prohibit the carrier from earning more than what is paid to the provider. Demand transparency and define “savings” in measurable, meaningful terms. 2. Limit Out-of-Network Services:Consider eliminating or tightly restricting out-of-network benefits. Handle exceptions individually to ensure members get needed care without giving carriers an open invitation to pad their margins. 3. Engage Expert Negotiators:Partner with advisors who understand these complex billing games. They’ll ensure plan language and fee structures minimize the potential for misaligned incentives. Implementing these strategic approaches can reduce your per-employee per-month (PEPM) costs significantly. In fact, by addressing just one out-of-network program, some employers have seen immediate reductions of up to 7.5% of total healthcare spending. Data-Driven ResultsEmployers who actively root out these hidden fees and adopt transparent payment models have achieved substantial cost reductions. Data shows that organizations employing robust payment integrity strategies and strict out-of-network controls can drive down total health plan costs by as much as 15%. Your Next Move: Take Back ControlAs an executive, every dollar counts. In a landscape where healthcare spending spirals ever upward, protecting your plan from hidden charges and self-serving “savings” schemes is critical. Don’t leave your organization’s financial health to chance. Take the first step toward total transparency and meaningful savings. Contact us to learn more and schedule a consultation. Our team will review your existing arrangements, identify hidden waste, and help you negotiate a plan structure that truly prioritizes cost control. Stop letting opaque deals drain your resources—act now and put your company on the path to zero trend. Written by Rob Thwaites

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