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Today’s Panelists
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Jackie Adams
Panelist — Director, Benefits and People Analytics, Meijer |
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Claire Brockbank
Panelist — Director, 32BJ Health Fund |
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Lee Lewis
Presenter — Chief Strategy Officer, Health Transformation Alliance |
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Chatrane Birbal
Moderator — Senior VP, Practice, Policy and Government Relations, CHRO Association |
Incentives
Your Second-Largest Expense Runs on One Contract, and Carrier Interests Don’t Align With Yours
- Your dollars subsidize their book. Carriers need your plan to pay hospitals generously, so they can pay those same hospitals less on the Medicare Advantage and fully insured business where they carry the risk.
- The loopholes are real. Recent lawsuits show that, without safeguards, major gaps in these agreements have been exploited.
- Flat fees, rising everything else. Basic admin fees haven’t gone up in over a decade. Increases have been constant in other categories that are poorly reported.
Five Categories That Matter
| 1. Data. Everything else depends on seeing it. |
| 2. Fee transparency. Know every dollar; cap what varies. |
| 3. Audit rights. Check the work and get the money back. |
| 4. Carve-out rights. Freedom to buy better without a penalty. |
| 5. Steerage rights. Send members to higher-value care. |
Fee Transparency · What to Request
The “Dark Money” Categories Are Fees You Rarely See
Common areas where employers pay a lot, often without knowing it — each should be requested.
| 1. Shared savings on out-of-network claims. A percentage of the “savings” off billed charges, often with no cap. |
| 2. Operating fees mixed into claims. Payment-integrity and coordination-of-benefits fees taken from claim dollars. |
| 3. Unclaimed medical drug rebates. Rebates on drugs billed under the medical benefit that never reach the plan. |
| 4. Unreported provider incentive payments. Bonuses paid with plan dollars, with no report of who earned what. |
| 5. Independent Dispute Resolution (IDR) losses. Surprise-billing arbitration awards the plan pays, rarely reported. |
| 6. BlueCard fees. BCBS plans only. Access and out-of-area fees billed on top of the admin fee. |
Take-Home
The Fine-Print Checklist
Data
- Plan controls claims data
- Claim-line feeds, no fee
- No gag clauses
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Fees
- Every fee on one exhibit
- A cap on every variable fee
- Lesser of contract or billed
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Carve-outs
- Right to carve out or add on
- Fees drop when services leave
- Direct contracts allowed
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Audit
- Your auditor, your sample
- No fee on your findings
- Unrestricted fiduciary review okay
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Steerage
- Navigators at point of care
- Anti-steering terms disclosed
- Right to exclude providers
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Control and Exit
- Plan document governs
- No changes without consent
- 90-day exit, no penalty
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Take-Home · Before Your Renewal
Questions to Ask Your Carrier
| 1. Data: Will you please help us set up a monthly comprehensive claims data feed to our designated server? |
| 2. Fees: Please share how much we spent last quarter on shared savings and payment integrity fees. |
| 3. Transparency: Please provide a report on last quarter’s medical drug rebates and provider value payments. |
| 4. Pricing: Which of our claims in the last year exceeded billed charges? Provide number and amounts. |
| 5. Carve-outs: We need the option to carve out specialty drugs; is this permitted or must we go to RFP to do this? |
| 6. Audit: Will you resist our performance of a targeted claims audit with a standard sample? |
| 7. Steerage: What is the process to implement a two-tier in-network benefit to incentivize high value utilization? |
Category 1 of 5 · Data: You Can’t Manage What You Can’t See
| The default |
The fix |
- Data treated as the carrier’s property
- Summary reports, not claim-line detail
- NDAs and fees before vendors get feeds
- Denials and adjustments left out
- Data held hostage at termination
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- Claims data owned by the plan
- Claim-line feeds, denials included
- Sent to vendors you choose, at no fee
- No gag clauses; yearly attestation
- All data handed over when you leave
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Start here: request a monthly claim report to a server you control. Either your servers or you can outsource, so long as you can withdraw your paid claims data whenever desired. Your next gag-clause attestation is due December 31, 2026.
Category 2 of 5 · Fee Transparency: The Base Fee Isn’t the Whole Fee
| The default |
The fix |
- A flat admin fee in the headline
- Percent-of-savings fees with no cap
- Up to a third of recoveries kept as fees
- Bonuses and fees buried in claim costs
- Fee changes “deemed” accepted
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- Every dollar of pay on one fee exhibit
- Anything else refunded, with interest
- A cap on every variable fee
- Fees billed separately, never in claims
- Changes only with written consent
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Start here: ask for total compensation earned from your plan last year — every source, not just the admin fee.
Category 3 of 5 · Carve-out Rights: Keep the Freedom to Buy Better
| The default |
The fix |
- Only the carrier deals with providers
- Direct contracts restricted or penalized
- Carving out a service raises your fees
- New programs added without asking
- Exit fees and long notice periods
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- Right to insource, carve out or add on
- Direct contracts paid as you set them
- Fees go down when services leave
- Your plan document governs
- 90-day exit, no penalty, partial allowed
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Start here: find every clause that makes a carve-out cost you — then price what a better vendor would save.
Who Really Runs Your Plan?
| What the fine print says |
What it should say |
| Fee and program changes take effect unless you object |
Changes require your written consent |
| Carrier medical policies and provider contracts override your plan document |
Your plan document governs every conflict |
| The carrier has the final say on what the plan means |
You stay the named fiduciary; they decide initial claims and appeals only |
| Only the carrier may negotiate with, audit, or contact providers |
You can direct contract, carve out, and add your own vendors |
Start here: find which document wins when your plan and the carrier’s policies conflict.
Category 4 of 5 · Audit Rights: The Right to Audit, on Paper Only
| The default |
The fix |
- Once a year, a few hundred claims at most
- Random sample only, no extrapolation
- Carrier approves the auditor; NDAs first
- No recovering directly from providers
- Repaid as offsets against future claims
- Up to a third kept as a recovery fee
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- Unlimited claim reviews, pre- or post-pay
- Your sampling method, your auditor
- Errors fixed on every matching claim
- No fee on overpayments you find
- Recoveries paid in cash within 60 days
- Audit rights for 36 months after you leave
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Start here: read your audit clause for sample limits, auditor approval, recovery fees, and how long rights last after you leave.
Category 5 of 5 · Steerage Rights: Point Members to Better Care
| The default |
The fix |
- Carrier decides how providers appear
- Anti-steering terms hidden in contracts
- Navigators locked out at point of care
- No real-time eligibility for vendors
- No way to exclude poor-value providers
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- Add navigation and prior-auth vendors
- Real-time eligibility and cost-share feeds
- Disclosure of anti-steering and MFN terms
- Benefit design that rewards better sites
- Right to exclude providers from the plan
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Start here: ask which of your top 20 providers’ contracts limit steering, tiering or exclusion.
Renewal Negotiation
Hold Firm on Six Terms. Trade on the Rest.
| Hold firm |
Room to trade |
- Claims data shareable by the plan — no gag clauses
- Every dollar of compensation on one fee exhibit
- Benefits are capped at billed charges
- Carve out services without penalty
- Audits you control, with no fee on what you find
- Freedom to steer members, and your plan document governs
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- Performance-guarantee levels
- Audit timing and notice
- Report formats and cadence
- Term length for fee guarantees
- Implementation credits
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Review at every renewal, not only at RFP time. A term that slips through once becomes next year’s baseline.