EVHC creates a financially sustainable future for a mid-market employer running out of options.
The Challenge
The Challenge
Rising Costs, A Looming Deadline, and a Labyrinth of Choices

Facing an annual average health insurance premium increase of 23.5% with their current carrier, Anthem, after enduring increases for the past three years, a New York-based employer with 800 employees was teetering on the edge of eliminating medical benefits entirely—a drastic measure that could profoundly impact employee welfare and significantly damage the employer's ability to attract and retain talent. This dire financial situation jeopardized the brokers' two-decade-long relationship with the client. It underscored a critical need for innovative ideas and a transformative approach, not just to revitalize the renewal conversation but also to salvage the relationship and stabilize the client’s healthcare spending.

To understand the depth of the crisis, consider the immediate challenges facing the client:

  • Escalating Annual Premiums: A relentless climb in premiums, exacerbated by high claim years and costly pharmaceutical benefits, strained the employer’s budget beyond sustainability.
  • Recent Insurance Volatility: A tumultuous history of switching carriers each year for the past three years complicated the task of obtaining competitive quotes.
  • At-Risk Benefits: The soaring costs pushed the employer to consider cutting medical benefits for their 800-life group altogether.

The broker faced their own set of challenges, particularly their need to not only assemble but also persuasively pitch a self-funding proposal to a client who had previously been led to believe that self-funding was not a viable option:

  • Need for a Strategic Partner: The situation's complexity underscored the necessity for a strategic partner capable of introducing innovative perspectives and tangible tools for better control and transparency in managing healthcare costs.
  • Limited Expertise and Resources: The broker, though experienced, lacked the specific knowledge and resources essential for navigating the self-funded insurance landscape effectively. They needed a partner who could provide:
    • A purpose-driven approach to crafting insurance solutions
    • Strong relationships within the insurance markets
    • A meticulous and strategic review of claims data to facilitate informed negotiations
    • Expert underwriters skilled in customizing solutions for complex needs
    • A comprehensive panel of stop-loss insurers

The pressure was intense with only a few months remaining to secure a viable solution for an effective date that was just over a month away. The broker needed to quickly align with a new partner who could deliver immediate results and long-term stability, making the case for EVHC’s expertise and resources all the more critical.

The Solution
The Solution
Swift & Strategic Self-Funding Proposal from EVHC

In partnership with EVHC, the broker team leveraged the potential of partially self-funded insurance, delivering significant cost savings and enhanced coverage options:

  • Prescription Plan Overhaul: Revamped the prescription benefits plan, which anticipated annual savings of $276,266.
  • Comprehensive Market Relationships and Claims Analysis: Utilized EVHC's extensive industry connections and data-driven claims analysis to refine the client’s insurance strategy, emphasizing sustainable cost-saving strategies and long-term coverage options.

Extensive education on self-funding culminated in a significant "Ah-ha" moment for the client during the proposal presentation:

  • Breaking Down Costs: The proposal clearly differentiated between fixed costs and claims liability, demonstrating how self-funding allows for better budget control than their current fully insured model.
  • Visibility and Control: The presentation showed that with a self-funded model, the company would save on fixed costs and have clear insight and control over spending. This clarity revealed potential savings on variable costs based on actual claims data.
  • Budget Maximization: The presentation highlighted that any money set aside for maximum potential claims stays in the company’s bank accounts, meaning any unused funds can be kept by the company instead of paid out to the insurer—a key advantage of the self-funding model.
  • Operational Control: Detailed how claims management under self-funding works and the various opportunities to optimize for both comprehensive coverage and overall savings, leading to the realization: “Why haven't we done this before? EVHC is a well-oiled machine."

 

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The Results
A Victory for Cost-Efficiency and Coverage Integrity

The switch to EVHC's tailored self-funded insurance plan resulted in an anticipated total savings of $2,332,602 in the first plan year.

EVHC was able to accomplish this by:

  • Plan Design & Carrier Relations - The new plan, enhanced by strategic benefit changes, projected an expected increase of just +2.74%—a considerable improvement over the potential maximum increase, highlighting substantial savings and effective cost management.
  • Pharmacy - With guidance from EVHC, the broker team managed to cut the client's prescription drug expenses, yielding an additional annual savings of about $276,266.
  • Proactive Case Management - As the year progresses and claims are processed, EVHC will continue to assist the broker and client in realizing additional savings through the comprehensive '3T approach.’
  • The integrated approach - including proactive cost control and dedicated case management—helped the broker team present a convincing proposal that won them the business and positioned the client for a more financially sustainable future. The broker, now equipped with a compelling, cost-effective solution, solidified their position as strategic advisors in their client's eyes.

Recent Case Studies

EVHC Helps Company Save $22,000 a Month by Not Auto-Adjudicating
EVHC Helps Company Save $22,000 a Month by Not Auto-Adjudicating

Hands-on approach saves company--now and in the future--with a custom health plan Save Thousands of Dollars, Hours, and Headaches Providing employees with high quality healthcare for severe health conditions like arthritis or certain diseases can be hard on companies’ bottom lines and employees’ bank accounts. And frequent visits to doctor’s offices or hospitals can be exhausting and take a toll on a patient’s mental well-being. One of EVHC’s customers experienced these challenges firsthand. An employee was receiving regular treatments of Remicade, a drug that treats arthritis and other ailments. Every six weeks, the employee had to travel 40+ miles round trip to and from the hospital and spend six hours receiving the infusions. Each treatment cost the employees’ company a staggering $27,000. Before turning to EVHC, the company and employee just accepted this situation—but it didn’t have to be this way. The expensive, time consuming, and exhausting process was the result of auto adjudication from the employer’s fully funded carrier. Auto-adjudication is when an insurance company pays or denies an insurance claim automatically, without actually looking closely at the claim. Injectable drugs like Remicade are often auto adjudicated by carriers, who don’t bother to try and help employers and plan members save headaches and money. This employer and plan member had enough. So, they contacted EVHC. Stop Auto-Adjudicating! Unlike traditional fully insured carriers, which typically auto-adjudicate 90% of claims, we limit our auto adjudication to 65% of claims. Instead of automatically passing along higher costs, we pour over complex cases to help clients—like the one depending on Remicade—save time, money, and their sanity. Our process doesn’t just help employers save money in the short-term—it also helps them avoid paying higher premiums when it comes time to renew. Not auto-adjudicating every claim keeps companies from having to exceed their specific insurance coverage and resort to stop-loss. When an employer goes into stop-loss, fully insured carriers will pay the overage—but to make up that money, they’ll jack up next year’s premiums. This costs companies and their employees a lot of money that could have been saved if their carriers had been willing to work with them in the first place. Save $22,000 a Month (and Wear Fuzzy Slippers) Fortunately, our customer found EVHC. We were not only willing to work with them, we were also willing go the extra mile to save them and their employee a lot of money, time, and energy. Immediately, our representatives went to work to find an alternative to the frequent trips to the hospital. The answer was simple: home healthcare treatments. We worked with the employer and the employee and their physician to get a home health regimen approved, planned, and implemented. The physician also wrote a prescription for Remicade that the employer could pick up at a local pharmacy—a far better option than driving 40 miles. Both the employer and employee benefitted from this plan:

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EVHC Helps Company Save More Than $500,000
EVHC Helps Company Save More Than $500,000

Partially self-funded insurance reduces costs by 28% with no coverage loss Save without Sacrifice Each year, health insurance premiums go up, forcing employers to shop around and, usually, ending up right back at square one. Whatever they do, companies end up paying more than they should because the alternative—reducing benefits or limiting network access—is simply not an option. Tired of the costs and headaches associated with fully insured options, one company began to explore the benefits of partially self-funded insurance and how it could help them: -Keep their margins (the difference between claims liability and actuarially expected claims) -Cut pharmacy spending -Retain access to the nation’s largest provider networks “We needed a solution that allowed us to save money while still providing our employees with access to the best provider networks. We weren’t getting that through traditional fully-funded insurance.” EVHC’s Partially Self-funded Insurance The company turned to EVHC, which offers custom plan designs that help companies save money without losing coverage. Through EVHC, the company had: -Access to three of the nation’s four largest provider networks -24/7 concierge-level customer service, including member education programs -Flexible plan designs -Greater price transparency “EVHC was easy to work with and a true partner. They were there every step of the way, from implementation to enrollment and beyond.” Thousands Saved, No Coverage Lost In just one year, the company experienced:

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