Many self-insured employers are reviewing annual agreements for 2013 benefits. While this list isn’t exhaustive (and each topic could indeed have an entire blog post on its own), here’s a quick checklist for handy reference before you sign on the dotted line.

Price & performance guarantees. Try to negotiate rates up front for two or three years. Service, clinical, pharmacy, and network discount savings should be on the line. If your provider isn’t evaluating their own performance, how can you?

Claim audits. Some carriers restrict the number of claims, frequency, and even specific providers to conduct audits. Request a separate contract from the Administrative Services Only (ASO) agreement.  You can always hammer out these details later – it will be to your advantage. 

Carve-out pricing. Find out in advance how much it will cost if you carve out services like disease management, case management, pharmacy benefits, stop loss, transplant networks, and more. 

Implementation & data transmission. If you’re switching to a new carrier, how will the data be transferred? Can you load historical data too? Will there be fees from the prior carrier and the new one? 

Eligibility. Will the data load be manual or use an electronic data interface file? What type of support will the carrier provide? Who will build and test the file? These costs are usually forgotten during finalist presentations.

Pharmacy. Ask for transparent model pricing. This allows the pharmacy benefit manager to pass full rebates to you, in exchange for a higher admin fee. If the transparent model isn’t feasible, then definitely negotiate for the rebates and get it all in writing.

Network. Have you adequately reviewed the networks? Are large hospital systems excluded in your coverage areas? Nothing breaks the bank more than out-of-network ER visits billed at rack rate. 

Capitation. Ask in advance what types of capitation claim programs exist. These are similar to “membership” agreements and result in full claims replacement. Depending on utilization, this can save a ton, but for some plans it can cost more. Ask for a full analysis.

Disease management, case management, and nurse access. Whether it’s your carrier or a carve-out provider, be sure to not only review fees, but also what type of guarantees and reporting will be offered. Explore how the claimants will be engaged in the program and what type of data the carrier needs for outreach – some carriers don’t even load updated phone numbers.

Transplant networks. Most carriers use centers of excellence for transplants. They not only save the plan money, but the member, too. The cost savings will astound you.

Subrogation & shared savings. Ask how claims are referred, dollar thresholds to pursue (some have dollar minimums), and how often they “sweep” claims. I’ve found that most providers don’t offer detailed reporting unless you ask. 

Explanation of benefits delivery. This is a pet peeve of mine. How can I help my members to be good consumers if they don’t mail EOBs every time they process a claim? Online access is convenient, but an EOB in the mail packs a punch.

Wellness. Assistance with your wellness programs should be standard. If your carrier proposes a projected savings to buy into its programs, ask for an offset of funds to be used towards the program.  Ante up.

Stop loss. Try to get a “mirror” clause to protect your plan from any excluded claims, especially for carve-out arrangements.

Reporting fees. If you request detailed reporting, the price tag can be an unwelcome surprise. Find out the average costs.

Run-out provisions. Sometimes employers switch carriers to save, but leaving costs money, too. Find out in advance the costs of terminal liability and claim run-out processing. 

Unfortunately, I’ve run over my word count. Perhaps I’ll blog more about consumerism, claims integration, and national contract pricing agreements. Until then, this list is a good place to start. Chime in and share your good ideas in the comments, too!

Karrie Andes, SPHR, CBP, is the senior benefits manager for PGi and a savvy self-funding health care  gal.  She’s located in the Kansas City area and can be reached at

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