SELF-FUNDED EMPLOYERS / TPA’s

SOLUTIONS FOR SELF-FUNDED EMPLOYERS, LABOR UNIONS, AND GROUP HEALTH PURCHASERS

Since 1974, employer self-funded health and welfare benefit plans have struggled to control rising health benefits expenditures. In recent years the trend has been to shift higher percentages of cost burdens to plan participants and their dependents and forcing them to use much narrower provider networks. When we narrow local access to healthcare provider networks and raise out-of-pocket costs, delayed access to care results in direct and indirect costs with the largest percentage of the costs absorbed ultimately by the employer or plan sponsor.

• Presenteesim: Your employees are at  work but not fully-functioning in the workplace because of an illness, injury or other condition. They are distracted by worry about the cost of their financial responsibility, so they delay care, come to work in pain, on pain medications, moving slower, thinking less clearly and pre-occupied. Jobs with large workloads are associated with presenteeism. People whose self-esteem is based on performance, as well as workaholics, typically have high levels of presenteeism. You are paying for every minute of their time on the job.
• Delayed intervention – increased acuity and higher risk of chronic disease – Narrow network options often results in impacts such as long waits for appointments. The delay, in turn, leads to more presenteeism and ultimately, the risk of higher costs associated with delayed access to care, due to appointment shortages and difficulties with patient access, or patient financial hardships associated with high-deductibles and copayments for more expensive care. Pushing back care and self-neglect only drive complexity and costs higher for all concerned.
• Sketchy worker’s comp incidents – when there’s a huge out-of-pocket exposure, we often encounter downright dubious mechanism of injury stories about how the patient was injury. Could it be that the problem was pre-existing and a slight twist or movement was the last straw? Oh, it happened at work? Hmm, workers comp will cover the initial visit and the surgery with a zero out-of-pocket cost. You are one short initial notice of injury form away from absorbing costs you didn’t plan to cover through workers’ compensation coverage.
• Absenteeism – Time off work, with pay through your usual sick day or PTO bank, or pay through workers’ compensation is an indirect cost associated with delayed intervention. Acuity increases and complicates recovery, and you may be paying two or three times more to cover temporary coverage at premium pay, or lost productivity.
• High local network prices – The network you lease may not advocate for you for lower prices from healthcare providers. while this sounds counter-intuitive, it isn’t. For instance, do you know for sure that your providers aren’t forced by contract to kickback a percentage of revenue (often as high as 12%) that comes from your health plan member expenses to the TPA? So the network turns a blind eye to the rates negotiated because if they pay the provider more of your trust fund dollars, they get a higher percentage return on that 12% kickback. Either way, you and your plan participants are the ones paying every penny of the cost, the PEPM network leasing fee, the PEPM TPA fee, the broker’s commission, and the kickback amounts. What’s worse is that the prices are not yet transparent, reliable, predictable, or the posted prices aren’t meaningful. And the more remote your local community and limited you have in competition and choice, the higher your local prices will be.

What if you could change all 5 of these challenges (and more) with a single phone call?

Self Funded Solutions

St. George Surgical posts all-inclusive pricing on over 220 Out-patient surgical procedures. This pricing includes Surgeon Fees, SGSC Facility Fees, Anesthesia, Implants, and Overnight stay, if necessary. The result is 50 to 90 percent savings over Hospital Fees, resulting in a direct savings to your company’s Bottom Line. Savings from just a few surgeries can add up fast, as shown in the recent, real-life examples below.

Hospital Cost Comparison vs. SGSC Bundled Pricing

TOTAL SAVINGS: $234,784

SGSC’s Transparent Pricing Model is Ideal for Self-Funded Employers

Our direct-contracted employers realize hard dollar (often $15,000 or more, per case) savings on scheduled surgery procedures because we eliminate several direct and indirect costs of healthcare.

Our pricing is a transparent, set amount for a defined episode of care with quality you can count on. We negotiate up front on the bundled-price procedure. You pay the predictable negotiated amount. No reference-based pricing, no surprises, no need for audited bills, medical records reviews, no repricing fees, and one single line item bill that covers the facility fee, surgical fee, anesthesia costs, implants or hardware, and physician fees, and if medically necessary, we can offer an overnight stay in our facility with around the clock nursing care, or at a skilled nursing facility.

One of the 5-star accommodations we use for our patients, a serviced private “casita”.

How It Works

Your employees and dependents have their local hometown doctor consultation. If surgery is recommended, call us. 1 (844) 673-0095k, toll free from USA or Canada.

We’ll first confirm that we offer the procedure. If it isn’t one of the 220 we already have posted, we’ll work up the bundled price.

We’ll likely ask for a copy of the doctor’s note and any previous xrays, MRIs, CT, or other imaging studies. Our surgeons will review the case and accept or decline the case. If they accept the case, they advise any other testing that may be required and offer some surgery dates and times.

If you agree to cover the cost of the surgery, (in- or out-of-network) a date and time is booked and a pre-authorization form is signed by the Plan Administrator. Your signature is regarded as a Purchase Order.

Many employers also cover the travel/transportation costs for the patient and a companion, and accommodations at our pre-arranged, exclusive discount rates for their entire stay (Usually two business days prior and 1-3 days post-surgery.)  Airfare is often covered as well, flying directly into St George from Denver, Los Angeles, Salt Lake City, Phoenix, and Dallas, using American, Delta and United and soon Allegiant, through Tempe. Or alternatively into Cedar City (CDC) or Las Vegas, 2 hours south of our location. We will help arrange all the travel upon request.  All air travel, per diem and accommodation can be paid by ACH, credit or debit card, or a single check along with the pre-payment for the surgical case rate. Self-drive patients can simply submit their mileage record and other receipts to you for reimbursement.

Our program for domestic surgical travel launched in  2015 and has grown in popularity. We’ve received patients from 40 states and from parts of Canada. Surgical savings are substantial enough that many employers waive plan deductibles and co-pays, cover travel expenses, and still save a huge amount of money. They saved on the surgery case fees, they saved on reduction of presenteeism, they saved on TPA line-item fees and embedded kickbacks, they saved on repricing, audits and per check fees for provider settlement costs. Their plan participants accessed care sooner and easier and at a lower out-of-pocket expense.  They even saved on workers’ comp cases. They saved on healthcare expenses for lasered plan participants. They enjoyed predictable, reliable and transparent costs that were significantly lower than in-network prices. They accessed care in accredited facilities with lower than national average infection and complication rates and very high patient satisfaction and clinical outcomes scores.

Happy Outcomes and Plan Beneficiary Satisfaction

• Employee is happy, healthy, and financially more secure, and feels fortunate to work for an employer who cares
• Employer has a happy, healthy, stable, and loyal employee who is back to work quicker and less distracted by pain or worry.
• Everyone saves on lower healthcare claims costs.

Extraordinary value for money. High-quality. Low hassle factor.