Enhancing Fiduciary Responsibilities

March 24, 2025

A Strategic Approach to Cost Containment for TPAs and Plan Sponsors

In the complex environment of managing today's self-insured health plans, employers, plan sponsors and third-party administrators (TPAs) that exercise discretion or control over the plan find themselves under increased scrutiny. Business leaders received a wake-up call earlier this year when a lawsuit alleged that a manufacturer breached its fiduciary duties by not taking proper measures to ensure its plan costs were reasonable -- among other issues related to pharmacy benefit manager (PBM) contract terms.

With rising healthcare expenses and increasing regulatory oversight, the stakes for fiduciaries have never been higher. At the H.H.C. Group, our dual focus on clinical and financial claim evaluations are the underpinning of the support we provide to our clients. By adhering to best practices and offering tailored solutions designed to maximize savings on all claims – especially high-cost in-network and out-of-network claims -- our expert negotiating team is positioned as a trusted partner.

Empowered with a comprehensive suite of tools and technology, our attorney case managers address both the clinical and financial aspects of every claim. These strategic capabilities ensure that all decisions are both cost-effective and compliant with industry standards.

A Commitment to Quality, Compliance and Savings

Our innovative cost-containment strategies and expert-driven solutions ensure compliance with Employee Retirement Income Security Act (ERISA) standards, reflecting a deep understanding of regulations and offering strategic guidance to safeguard plan assets. Ongoing accreditation by URAC is further evidence of our role as an indispensable resource for fiduciaries seeking to optimize healthcare management and cost savings.

What's more, H.H.C. was selected as one of five Independent Dispute Resolution Entities (IDREs) for New York State to determine the amount that providers receive for thousands of cases. Reviewing the documentation sent by payors and providers continually adds to our knowledge of what is a reasonable amount to pay on a claim – down to the CPT code. This experience with large dollar in-and=out-of-network claims arms our case managers with knowledge to convince provider decision-makers to reduce their bills to a more appropriate amount.

Clients rely upon our attention to line-item detail, accuracy and determining medical necessity for claims. They also value our rapid turnaround times – about 5-7 days -- the fastest in the industry.

Navigating Fiduciary Responsibility: Challenges and Expectations

Meeting fiduciary responsibilities is further complicated by several key challenges in today's healthcare landscape:

• Rising Healthcare Costs: Out-of-network claims, specialty drug pricing, and high-cost procedures place significant strain on plan resources.
• Regulatory Compliance: Adhering to laws like the No Surprises Act and ERISA demands constant vigilance and precise execution.
• Fraud, Waste, and Abuse: Identifying and mitigating improper claims requires sophisticated tools and a thorough review process.
• Balancing Cost and Care: Striking the right balance between containing costs and maintaining care quality is a persistent challenge.

Comprehensive Solutions to Support Fiduciary Responsibility

Independent Medical Reviews are a cornerstone of this approach, offering objective evaluations to ensure claims are medically necessary and appropriate. URAC-accredited reviews uphold the highest standards of compliance and impartiality, providing the reliability fiduciaries need.

Claims Negotiation and Repricing further enhance cost control by reducing excessive charges for both in-network and out-of-network claims. Transparent processes eliminate unnecessary expenses while preventing balance billing for participants, protecting plan assets without compromising care.

Fraud Detection and Prevention is achieved through advanced data analytics and expert reviews. Comprehensive audits help uncover errors, fraud and abuse, ensuring claim accuracy and adherence to fee schedules.

Reference-Based Pricing provides a framework for aligning payment models with Medicare or other benchmarks, ensuring consistent and fair pricing. This method reduces overpayments while maintaining provider satisfaction and transparency.

Technology-Driven Solutions like automation and AI streamline claims review, minimize manual errors and expedite resolutions. Predictive modeling uncovers trends and opportunities for cost savings, enabling more informed decision-making.

Building a Sustainable Future in Fiduciary Management

Enhancing fiduciary responsibility goes beyond simply mitigating risks. It focuses on developing a sustainable approach to healthcare management that achieves long-term value. By implementing rigorous cost-containment strategies, TPAs and plan sponsors can protect plan assets, strengthen compliance to reduce liability risks and achieve measurable savings while improving outcomes for participants.

Partnering with H.H.C. Group empowers fiduciaries to meet these critical objectives with precision, efficiency and integrity. It's a level of support that safeguards the interests of plan participants and beneficiaries while ensuring financial stability for plan sponsors.

Contact H.H.C. Group today to learn how our tailored solutions can transform your approach to plan management and ensure sustainable success.