About Us:

Learning Process:

We are continuously amazed at what we find when asked to review an employer's insurance program:

• A small North Texas bank with 300 employees was paying their health insurance agent over $100,000 a year and did not know it until we reviewed the fund accounting.
• A Third Party Administrator was found to be inflating their projected fixed costs by hiding certain fees in the claim ledger side of the accounting.
• A Third Party Administrator was found to be charging a monthly administrative fee per employee plus a $10 per claim transaction fee. Through careful review we found that many claims were unbundled into three or four claims with the $10 claim transaction fee applied to each.
• An agent, in collusion with a Pharmacy Benefit Manager, was paid a $3 commission each time an employee or dependent purchased a prescription drug at the pharmacy. This was not disclosed to the employer.
• A Third Party Administrator was “spread pricing” prescription drugs, charging the employer a 100% markup on retail prescription drug costs, without disclosing the arrangement to the employer.
• A carrier, refusing to disclose their proprietary PPO discount arrangements with area providers, was found to be collecting a percentage of the savings on every claim without disclosure.
• A municipality with 280 employees was found paying over $500,000 in fixed costs when they thought they were only paying $218,000 in fixed costs. The difference was hidden on the claim side of the ledger.
• A municipality was paying $67 per dental claim. The plan cost more to pay most claims than the claims themselves.
• An agent, who refused to disclose commissions in a Request for Proposal process, finally disclosed commissions of approximately $24,000. The carrier, when asked, disclosed that the agent was also getting a bonus arrangement, persistence bonus as well as General Agent over-rides.
• A carrier was asked to provide claim data showing "submitted claims" versus "paid claims". Instead, the carrier provided a claim report showing "allowed charges" versus "paid claims". (If you dont understand the implication here, you need our help)
• Would you sign an Administration Agreement that said "we are going to make money on every component of our contract, some with subcontractors, but you agree not to ask us how much, from whom, or through which subcontractor and we agree not to tell you." A 700 employee life retail business did.
• An employer was charged a percentage of savings on this PPO contract rather than a pepm fee of $3.50. We showed the employer that he was effectively paying $23.84 pepm under this arrangement, or over $70,000 too much per year.
• A group health plan was being charged a $25 administration fee for every claim adjudicated more than one once. This effectively raised claim administration costs by more than 10%
• A PPO "Provider Repricing Fee" of 4% was discovered. The arrangement was between a PPO Network Provider and a Medical Provider, but the self funded employee welfare plan was not aware of this arrangement. The 4% fees were a "claim charge" hidden within the claim runs.
• "A PPO network negotiated a special contract with a local hospital for one of our clients. We asked for a copy of the PPO contract for review. Request was denied, so we repriced a sampling of in-patient claims and found the PPO rates to be 200-800% of Medicare! "

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