sample employer health plan proposal

It’s here. It’s time.

Re-Thinking the Traditional Health Plan with YOUR BUSINESS in Mind

HLU Open-Platform Health Plan Proposal for

Company Name HereDate Here

Prepared by:

Mark GallHealth Plan Consultant

513.559.7502 [email protected]

HLU CONSULTANTS | Reclaim Control of Your Health Plan2

It’s an open-platform health plan that provides the highest quality benefits at the lowest costs with better employee health outcomes.

An exciting change for the better, this efficient and cost-effective self-funded plan allows employees and employers to reclaim ownership of their healthcare benefits and costs.

It provides data you can act on and use to tailor your plan for the greatest value . . . it’s structured around a long-

term strategy to continually control plan design effectiveness and costs . . . and, it simplifies administration and compliance along the way.

For the employee, it’s empowering. HLU’s Open-Platform Health Plan provides employees with educational resources to help them make informed decisions to select the best available healthcare plans and options for their needs. The result . . . better employee health and lower plan costs.

We offer a smarter approach.

3hluconsultants.com | 513.559.7503 | [email protected]

The Consultant vs. The BrokerTake your pick: A fully customized solution or one-size-fits-all product?Don’t be misled. When expressing your interest in open-platform, your broker may quickly try to discredit the self-funded model or promise a “canned” product to match. But how can this be trustworthy advice when it comes from someone who doesn’t know the ins and outs of self-funding or specialize in a proven approach with cost savings at the core?

The reality:HLU operates as an independent, objective consultant that isn’t limited to one set solution, but instead, collaborates with a whole network of benefits and partners.

No product can match our solution. A broker often sees the plan as a routine transaction/renewal, whereas we see a long-term solution that solves a specific problem.

Experts agree that out-of-control claim costs are the number one reason for high-cost health plans. Has your broker attempted to address this?

Education is first and foremost. You should know exactly how much your plan is spending on claims, and over-spending shouldn’t be accepted as the norm.

Tweaking traditional plan designs or switching insurance companies can only take you so far. Cost savings are only achievable if you tackle the root of the problem head-on.


How can your business possibly

keep up with such unpredictable hikes?

Here’s the thing –

But thingscan change . . .

Most companies have no idea how much their health claims are costing them or that the issue of excess, unnecessary charges has become so incredibly routine.

All too often, claims get processed and paid without a thorough review to catch errors and inconsistencies.

Common issues like overcharging, miscoding and duplicate charges are slipping through the cracks, resulting in ridiculously high payments that areeating away at your bottom line.


It’s simple. This is a smarter way to manage health benefits …one that works AND saves you money now and for the long-term. HLU Open-Platform Health Plan puts YOU back in control through:

Meaningful data with the ability to analyze, model and forecast … this significantly reduces the costs of administration, insurance and claims, and allows you to adapt your plan whenever and however needed

Better care and improved outcomes because employees are more engaged in their care … this leads to more effective disease management and reduces excess office visits, lab tests, hospital admissions, etc.

Thorough claims review to identify overcharges and billing errors and address them before claims are processed and paid

Best-in-class partnerships without being limited to a minimal number of vendors

A “pay for what you use” approach to care with a plan built from the most appropriate modules

Pricing transparency for medical services is achieved by giving employees the resources they need to make the best choices and avoid overpaying for provider services

Employee onboarding with 360-degree reporting and billing that’s seamless and integrated

FMLA and COBRA compliance that’s hands-free and full-service

ACA compliance and employee notifications for your added convenience

1095-C or 1094-C tracking and reporting

Why HLU Open-PlatformHealth Plan?


Why is HLU for You?Benefits Done Better

• We are fully independent consultants with each employer’s best interests in mind

• We have 55 years of experience in the industry, backed by ateam of professionals who truly understand what works in a plan and what doesn’t

• We are a focused and efficient company with national reach that takes an objective approach to finding the best vendors

• You’ll work in partnership with the same account representative who is focused on the full relationship, from sales to implementation and strategy

• You’ll receive one-on-one customer service with a high-touch, hands-on approach

• You’ll never have to worry about brand-name fees, incentives or sales driven by commission coming into play


Health Plan Basics

Typical Health Plan Costs Breakdown

The Claims Process

Claims 70%

Admin. 10%Insurance

20%

Employee HealthPlan ID Card

Health CareRecieved

Health CareProvider is Paid

EOB

Employee ReceivesExplanation of Benefits

Claim isProcessed

NationalBenefit

Administratorwith Advanced Claim

Processing andOne-on-One

Customer Service

Insurance CompanyClosed Platform

Claim ProcessNo transparency, control or analysis

HLU Open-PlatformClaim Process

OptionsTransparency

ControlAnalysis

Stop-LossInsurance

to Protect AgainstLarge Claims and

Provide Guarantees

The Employee Routine is Unchanged

What Happens During the Claims ProcessInvisible to Employee

Large ClaimReview

Itemized ClaimReview vs.

Summary or RBP

HR Services,ACA Compliance

and Payroll

PPO Enhancement

The Nerve Center:Controlled by the

Summary Plan Description(SPD)

DiseaseManagementand Wellness


HLU Puts Plan Control and Cost Savings Back in your Hands

Control of Health Plan Employer Insurance company Insurance company

Provider Network Access

Data Analysis & Forecasting

Large Claim CaseManagement Analysis

PPO Enhancement:Utilize Independent, Best-In-Class

Vendors to Reduce Claim Costs

Pricing Transparency forEmployee Medical Services

Customizable SummaryPlan Description (SPD)

Claim Review Procedure

Compliance & EmployeeOnboarding

HLU Open-Platform Health Planwith Healthcare Intelligence

Hybrid Plan PlatformASO, Insurance Company, Self-Funded,Level-Funded, Balance Funded Plans

Closed PlatformHumana, Anthem, UHC, MMOH,

Aetna, etc.

Traditional PPO Networks, National Accessand Customizable Networks

Typically 1 or 2 PPO options(One size fits all)

Typically 1 or 2 PPO options(One size fits all)

YES - actionable data Basic claims and expense overview onlyData is not actionable

No data provided

YES - actionable data No No

YES No No

YES No or limited No or limited

No or limited

YES Yes - with limitations No

Claims are itemized and reviewed forovercharges and billing errors

Full Service, Hands-Free Suite: FMLA, COBRA,5500, ERISA, ACA, FTE Record-Keeper and filings

Claims are passed through and paidby a summarized invoice

LimitedUsually reference materials only

Claims are passed through and paidby a summarized invoice


Intelligent Claim Review andPPO Enhancement

Do you think your PPO discount alone is enough to tackle the high prices of health care? It isn’t. Because such enormous pricing variations exist for the same services among hospital systems throughout the U.S., the integrity and effectiveness of PPO discounts are quickly diminished. Fortunately, HLU Consultants has a solution – Fair Pricing Review and PPO Enhancement programs – to level the playing field when health plans pay medical claims. Without an intervention like this to keep an eye on prices, though, costs keep increasing.

HLU’s Open-Platform Health Plan enhances the best PPO discounts from CIGNA, UHC, MMOH, AETNA, HealthSpan and others by comparing PPO claims to a National Fair Pricing Database.We don’t stop there, large claims are physician reviewed for clinical accuracy, something thatwill never happen with a Traditional Closed Platform Health Plan.

Bottom line, we’ll make sure you pay the lowest cost for your claims without disruptingyour employee or your business.

1. PPO Discount Model

• Applies a PPO negotiated discount to the retail “master list” price

• Claim is processed with no clinical or fair pricing review

• Has your insurance plan or broker ever given you a savings report on a large claim?

2. HLU PPO Enhancement

• Claim is processed through the most competitive PPO and claim is discounted

• Extra step: Claim is then compared to national fair pricing benchmarks. Large claims are itemized and physician reviewed for clinical accuracy

• 98% of adjusted claims are accepted bythe Provider

• The employee or the health plan is never responsible for hidden charges or disputed claim adjustments

3. Referenced Based Pricing, aka Tru Cost• No PPO is used. Claim is processed with no

clinical or fair pricing review

• Claims are processed and paid at a % of Medicare

• Disruptive to employees. Employee is responsible for balance bills

• Providers may not accept reference based pricing plans

• Google: “Cincinnati, New Insurance Plan Pits Employers Against Hospitals.”

PPO Example

Claim $100,000

PPO Discount (45%) - $45,000

Health Plan Responsibility $55,000

HLU Example

Claim $100,000

PPO Discount (45%) - $45,000

$55,000

Intelligent Claim Review

Fair Pricing Discount - $20,350

Clinical Review Discount - $6,600


Tru Cost Example

Claim $100,000

No PPO Discount - $0

No Intelligent Claim Review - $0

Medicare ReimbursementRate x 150% $33,750


Employee may use a Patient Advocate to settle the balance.


PPO EnhancementHLU Intelligent Claim ReviewLarge Claim Review Process

Universal Bill (UB) sent by hospital to HLU National TPA

TPA Adjudicates UB

TPA Applies PPO Discount to UB

HLU Intelligent Claim Review Requests Itemized Bill (IB)

HLU Intelligent Claim Review Digitizes IB

HLU Intelligent Claim Review MD LineItem Review

HLU Intelligent Claim Review Calculates Savings & Summary Report

Bill Paid

Employee is guaranteed to never be balance billed for PPO Enhancement discounts

98% of adjusted claims are accepted with no push-back from medical provider

Health plan is charged 25% of savings over and above the PPO discounted claims for an average savings of 25%

Claim review fees are accepted and covered by stop-loss insurance

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REVIEW EXAMPLES

CLINICALUnnecessary TestICU Bed Not Needed

INTEGRALUn-BundledRe-Bundled

REASONABLE & CUSTOMARY$1000 Toothbrush

ERRORSDuplicate Charges

NEVER EVENTSAmputate the Wrong Leg


Notes & Questions

Learn more about HLU Consultants:

It’s here. It’s time.

Are You Ready for aSmarter Health Plan that has YOUR BUSINESSin Mind?

Contact:

Mark GallHealth Plan Consultant

513.559.7502 [email protected]