Every dollar lost to TPA business schemes is a dollar that could have gone toward employee wages, better benefits, or simply making health care more affordable for those who need it most.
Actually, you can't have nationalized health insurance. Is bankrupted or in the rest to everyone who has tried it, except Germany, and they pay half again as much tax as well do AND HALF can't even afford a car
Norway, Sweden, Denmark, Japan. These countries have a good quality of life. The US has the Dumbest healthcare system in the world. The US is the only country on earth with a Private For Profit Healthcare System.
Can you name another country, other than the US, where thousands of people file for Bankruptcy over medical bills?
I don’t disagree with this. However, nobody ever seems to go after the greedy providers that charge exorbitant prices with immunity.
For some reason people only go after the payors as if they control provider pricing. Why not go after the ones truly creating the problem instead of constantly beating up the middle man?
Is it your expectation that government controlled healthcare will solve this or are you merely ok with using your neighbors money to continue overpaying for healthcare?
I have been in the TBA space for 30 years and can validate all of this. I have been intimately involved in the fight for transparency with both the consolidated appropriations act of 2021 and ERISA. I have spoke to stop loss partners and transparent PBMs who get pushback from brokers and the TPAs that they partner with asking for additional fees to put into a marketing bucket. Over the last several months I've been interviewing insurance brokers, HR folks and I truly believe they just don't know what the law is. Some have said it's a don't ask don't tell policy that if a client doesn't ask about indirect or direct compensation then they're not obligated to tell them. That is absolutely false, I've talked to the DOL directly about these issues and they interpret the law very clearly. I am creating a course and a checklist for employers and employees. In order for transparency to happen we must arm employees and employers with the law.
After Trump signed into law the Consolidated Appropriations Act of 2021, Biden ignored it for 4 years and few know anything about it. The Act requires any employer with any plan subject to DOL/ERISA oversight to provide complete transparency and disclosures under the 2012 Service Provider Disclosure Regulations, known as ERISA section 408(b)2, as to what their services are, what fees they charge, direct and indirect compensation and acknowledge their fiduciary status or lack there of. The Act focuses on three benefits, namely healthcare, dental and Pharmacy benefits/drugs.
There is a grass roots movement supported by the Behavioral Governance Institute and the Viking Cove Institute to get consultants certified as Healthcare Fiduciaries to help employers implement a process to manage these requirements.
We spend a lot of time in Spain these days. Great healthcare system. People speak very positively about it and their complaints seem tragi-comic to Americans. Costs low, access good, quality high. Spain has third highest life expectancy in the world, much higher than US.
I left UnitedHealthcare to work for a TPA owned by a not-for-profit healthcare company thinking it would be better. I was taking out utilization reports that showed an employer/client cost against our aggregate book of business to show where they were doing better than average or worse in order to manage optimum benefits (?). Discovered aggregate data had not been updated for three years and the company refused to update. They took a quarter and a year that told the story they wanted to promote.
Which legislators should we write about this? My insurance now has a TPA and I'm going to pay $12000 more out of pocket for my health care than when I had the "same" plan without a TPA.
Once again this boomer is telling LIES in order to protect the interests of himself and his boomer cronies.
Don’t be fooled by this guy, he’s doing little more than trying to create a BlueSky v2 echo chamber for health care.
Here are the real facts:
A self-funded plan, also known as a self-insured plan, is an employer-sponsored health insurance plan where the employer assumes the financial risks of providing health benefits to its employees, rather than paying fixed premiums to an insurance company. Below are key details about self-funded plans:
How Self-Funded Plans Work
• Direct Cost Responsibility: The employer pays for employee health claims directly out of its own funds as they occur, rather than paying a set monthly premium to an insurer.
• Administrative Services: Employers often hire a third-party administrator (TPA) or an insurance company to handle claims processing, provider networks, and other administrative tasks for a fee.
• Cash Flow Advantage: Employers only pay for actual claims, which can lead to cost savings if claims are lower than expected, but they bear the risk if claims are higher.
• Customization: Self-funded plans allow employers to tailor benefits, coverage, and plan design to meet specific employee needs, offering more flexibility than fully insured plans.
Key Components
• Stop-Loss Insurance: Many employers purchase stop-loss insurance to limit financial risk:
• Specific Stop-Loss: Caps the amount paid for an individual employee’s claims (e.g., $100,000 per employee).
• Aggregate Stop-Loss: Limits total claims for the group (e.g., 125% of expected claims).
• Claims Fund: Employers set aside funds, often in a trust, to cover anticipated claims and administrative costs.
• Plan Design: Employers can choose which benefits to cover, such as prescription drugs, mental health services, or wellness programs, and set copays, deductibles, and out-of-pocket maximums.
Prevalence
• In 2023, about 65% of covered workers in employer-sponsored health plans were in self-funded plans.
• Common among large firms (83% of workers in firms with 200+ employees) due to their ability to spread risk across a larger employee pool.
• Less common in small firms (18% of workers in firms with fewer than 200 employees) due to higher financial risk.
Advantages
• Cost Savings: Lower administrative costs (no insurer profit margins) and potential savings if claims are low.
• Flexibility: Greater control over plan design and coverage options.
• Transparency: Employers have access to detailed claims data, enabling better cost management and wellness initiatives.
• Tax Benefits: No premium taxes on self-funded plans, which can save 2-3% of costs.
Disadvantages
• Financial Risk: Employers bear the full cost of unexpectedly high claims, though stop-loss insurance mitigates this.
• Administrative Burden: Managing the plan requires expertise, often necessitating a TPA or in-house resources.
• Regulatory Compliance: Employers must comply with federal laws like ERISA, HIPAA, and ACA, which can be complex.
• Cash Flow Variability: Claims costs can fluctuate significantly month-to-month.
Regulatory Considerations
• Governed by the Employee Retirement Income Security Act (ERISA), which sets standards for plan management and reporting.
• Subject to Affordable Care Act (ACA) requirements, such as covering essential health benefits and preventive care.
• Some states impose regulations, but ERISA preempts many state insurance laws for self-funded plans, reducing regulatory overlap.
Who Uses Self-Funded Plans?
• Large Employers: Most common in firms with 200+ employees due to economies of scale and risk diversification.
• Union Plans: Many Taft-Hartley plans (union-employer trusts) are self-funded.
• Public Sector: Some government entities use self-funding for employee health benefits.
Trends (2023 Data)
• Self-funding continues to grow, with 61% of covered workers in firms with 50+ employees in self-funded plans in 2023, up from 60% in 2022.
• 94% of covered workers in firms with 5,000+ employees were in self-funded plans.
• Some smaller firms are exploring level-funded plans, a hybrid model combining self-funding with fixed monthly payments to stabilize cash flow.
Example
A company with 1,000 employees might set up a self-funded plan, budgeting $10 million for annual claims based on historical data. They hire a TPA for $500,000 annually and purchase stop-loss insurance with a $100,000 specific limit and a 125% aggregate limit. If claims total $8 million, the company saves $2 million compared to the budget, but if claims hit $12 million, stop-loss insurance covers the excess, limiting the employer’s liability.
Jerry- this is your plan for American healthcare? Self funded employer plans with third party administrators?
This ignores whole sectors of the population- our entire gig economy can’t use this solution. Contractors who are not employed can’t use this scheme. The unemployed can’t use this scheme.
Who is your intended audience? What are you selling?
We at Sentia Health are ready to take on new self-funded clients at $10/month with no brokers and no other TPA fees. Problem solved. Go read all about it right here on Substack. https://sentiahealth.substack.com
Sentia Health is a company based in Pottsboro, Texas, founded in 2014 by M. Kirk Jennings. It develops electronic medical records (EMR) software to manage health insurance data for patients, aiming to automate processes and reduce costs. The company offers a patient portal that analyzes checkup data and provides health prescriptions. It operates as an unfunded EHR platform with reported revenue of $5.6 million but no listed employees.
(Note: Sentia Health is distinct from Sentia Medical Sciences, which focuses on peptide therapeutics, and Sentia Healthcare, which manages primary care businesses in Australia.)
So yes, Jerry, this is a thing, and you don't know what you're talking about particularly with your TPA crap. Please refrain from commenting on my posts any more, you aren't qualified to even understand what is going on.
UHC has $400.3 B in revenue last year, are they doing it right?
No Jerry, you are closed minded and can't even drink when led to the water. this is the very definition of ignorance.
Your TPA gyrations are just more of the same, and perpetuating the processes that I have automated and not only ARE NOT WORKING, but MURDERING PEOPLE, through lack of access and lack of affordability.
No as stated earlier, I am tired of your trolling and willful, hateful ignorance.
Respectfully, you don't know what you are talking about. I am not only not part of the problem, but I am also the only viable solution. If you have a different opinion, I am open to hear it, but you are dead, murderously, wrong.
go ahead, tell me why I am the problem.
In fact, here is my solution:
Sentia has automated the entire health insurance process. We provide the EMR to practices, price the procedures 50% ABOVE Medicare, and pay for work performed in real time.
This eliminates medical coding, insurance networks, adjudication, delays, denials, rate negotiation, sales/brokers/agents, the cost of a third party EMR, skyscrapers in every major city in the US, and the hundreds of thousands of employees that work at the insurance company that you, as the insured, pay for.
For this service we charge $10 per month plus the actual cost of the risk (and stop loss/reinsurance). That alone should cut over 50% of the cost.
Further, we offer patient education based on the results of their lab tests. This happens automatically. When they read it, they get a small discount. When they follow it and get healthier, they get a large discount. This is scientific measurement and based on bloodwork. This gives the system 'teeth' by incentivizing healthy living. Then we start getting back some of the 84% spent on behavior based, chronic disease. Getting us down to the OECD average will save $1.34 trillion, or an additional 25%.
If you're so successful, why are we still taking about this? Clearly you've solved the problem. Not too bright are you? This is the only valid solution proposed anywhere. Tell me why I'm wrong, troll.
Wouldn't it be amazing if we had a little known thing called, SINGLE PAYER? I mean it's only worked in 100s of countries around the world for decades.
Dumbest comment ever posted.
Can you name those countries and their quality of life?
Actually, you can't have nationalized health insurance. Is bankrupted or in the rest to everyone who has tried it, except Germany, and they pay half again as much tax as well do AND HALF can't even afford a car
Norway, Sweden, Denmark, Japan. These countries have a good quality of life. The US has the Dumbest healthcare system in the world. The US is the only country on earth with a Private For Profit Healthcare System.
Can you name another country, other than the US, where thousands of people file for Bankruptcy over medical bills?
I don’t disagree with this. However, nobody ever seems to go after the greedy providers that charge exorbitant prices with immunity.
For some reason people only go after the payors as if they control provider pricing. Why not go after the ones truly creating the problem instead of constantly beating up the middle man?
Is it your expectation that government controlled healthcare will solve this or are you merely ok with using your neighbors money to continue overpaying for healthcare?
I have been in the TBA space for 30 years and can validate all of this. I have been intimately involved in the fight for transparency with both the consolidated appropriations act of 2021 and ERISA. I have spoke to stop loss partners and transparent PBMs who get pushback from brokers and the TPAs that they partner with asking for additional fees to put into a marketing bucket. Over the last several months I've been interviewing insurance brokers, HR folks and I truly believe they just don't know what the law is. Some have said it's a don't ask don't tell policy that if a client doesn't ask about indirect or direct compensation then they're not obligated to tell them. That is absolutely false, I've talked to the DOL directly about these issues and they interpret the law very clearly. I am creating a course and a checklist for employers and employees. In order for transparency to happen we must arm employees and employers with the law.
So, you know your boy Wendell that publishes this blog is a broker, don’t you?
Never met him, but definitely know of him
Yeah, don’t be a sucker.
Not sure I understand, there are a lot of great people in the industry.
Yes, there are. And none of them would ever post here. Smarten up 🫵
I am afraid I still don't understand
After Trump signed into law the Consolidated Appropriations Act of 2021, Biden ignored it for 4 years and few know anything about it. The Act requires any employer with any plan subject to DOL/ERISA oversight to provide complete transparency and disclosures under the 2012 Service Provider Disclosure Regulations, known as ERISA section 408(b)2, as to what their services are, what fees they charge, direct and indirect compensation and acknowledge their fiduciary status or lack there of. The Act focuses on three benefits, namely healthcare, dental and Pharmacy benefits/drugs.
There is a grass roots movement supported by the Behavioral Governance Institute and the Viking Cove Institute to get consultants certified as Healthcare Fiduciaries to help employers implement a process to manage these requirements.
So more layers? Awesome
This commenter is literally a nobody. Don’t be fooled
Go F yourself!
LOL Aren’t we the brilliant one 😂
Thankyou Wendell
Said the boomer
Hi Wendell, long time no see. Lots to catch up on. Reed Gelzer r.gelzer@TrustworthyEHR.com
We spend a lot of time in Spain these days. Great healthcare system. People speak very positively about it and their complaints seem tragi-comic to Americans. Costs low, access good, quality high. Spain has third highest life expectancy in the world, much higher than US.
Soooo, the protests in Spain decrying folks like you means what?
I left UnitedHealthcare to work for a TPA owned by a not-for-profit healthcare company thinking it would be better. I was taking out utilization reports that showed an employer/client cost against our aggregate book of business to show where they were doing better than average or worse in order to manage optimum benefits (?). Discovered aggregate data had not been updated for three years and the company refused to update. They took a quarter and a year that told the story they wanted to promote.
Medicare for all!!
Which legislators should we write about this? My insurance now has a TPA and I'm going to pay $12000 more out of pocket for my health care than when I had the "same" plan without a TPA.
Once again this boomer is telling LIES in order to protect the interests of himself and his boomer cronies.
Don’t be fooled by this guy, he’s doing little more than trying to create a BlueSky v2 echo chamber for health care.
Here are the real facts:
A self-funded plan, also known as a self-insured plan, is an employer-sponsored health insurance plan where the employer assumes the financial risks of providing health benefits to its employees, rather than paying fixed premiums to an insurance company. Below are key details about self-funded plans:
How Self-Funded Plans Work
• Direct Cost Responsibility: The employer pays for employee health claims directly out of its own funds as they occur, rather than paying a set monthly premium to an insurer.
• Administrative Services: Employers often hire a third-party administrator (TPA) or an insurance company to handle claims processing, provider networks, and other administrative tasks for a fee.
• Cash Flow Advantage: Employers only pay for actual claims, which can lead to cost savings if claims are lower than expected, but they bear the risk if claims are higher.
• Customization: Self-funded plans allow employers to tailor benefits, coverage, and plan design to meet specific employee needs, offering more flexibility than fully insured plans.
Key Components
• Stop-Loss Insurance: Many employers purchase stop-loss insurance to limit financial risk:
• Specific Stop-Loss: Caps the amount paid for an individual employee’s claims (e.g., $100,000 per employee).
• Aggregate Stop-Loss: Limits total claims for the group (e.g., 125% of expected claims).
• Claims Fund: Employers set aside funds, often in a trust, to cover anticipated claims and administrative costs.
• Plan Design: Employers can choose which benefits to cover, such as prescription drugs, mental health services, or wellness programs, and set copays, deductibles, and out-of-pocket maximums.
Prevalence
• In 2023, about 65% of covered workers in employer-sponsored health plans were in self-funded plans.
• Common among large firms (83% of workers in firms with 200+ employees) due to their ability to spread risk across a larger employee pool.
• Less common in small firms (18% of workers in firms with fewer than 200 employees) due to higher financial risk.
Advantages
• Cost Savings: Lower administrative costs (no insurer profit margins) and potential savings if claims are low.
• Flexibility: Greater control over plan design and coverage options.
• Transparency: Employers have access to detailed claims data, enabling better cost management and wellness initiatives.
• Tax Benefits: No premium taxes on self-funded plans, which can save 2-3% of costs.
Disadvantages
• Financial Risk: Employers bear the full cost of unexpectedly high claims, though stop-loss insurance mitigates this.
• Administrative Burden: Managing the plan requires expertise, often necessitating a TPA or in-house resources.
• Regulatory Compliance: Employers must comply with federal laws like ERISA, HIPAA, and ACA, which can be complex.
• Cash Flow Variability: Claims costs can fluctuate significantly month-to-month.
Regulatory Considerations
• Governed by the Employee Retirement Income Security Act (ERISA), which sets standards for plan management and reporting.
• Subject to Affordable Care Act (ACA) requirements, such as covering essential health benefits and preventive care.
• Some states impose regulations, but ERISA preempts many state insurance laws for self-funded plans, reducing regulatory overlap.
Who Uses Self-Funded Plans?
• Large Employers: Most common in firms with 200+ employees due to economies of scale and risk diversification.
• Union Plans: Many Taft-Hartley plans (union-employer trusts) are self-funded.
• Public Sector: Some government entities use self-funding for employee health benefits.
Trends (2023 Data)
• Self-funding continues to grow, with 61% of covered workers in firms with 50+ employees in self-funded plans in 2023, up from 60% in 2022.
• 94% of covered workers in firms with 5,000+ employees were in self-funded plans.
• Some smaller firms are exploring level-funded plans, a hybrid model combining self-funding with fixed monthly payments to stabilize cash flow.
Example
A company with 1,000 employees might set up a self-funded plan, budgeting $10 million for annual claims based on historical data. They hire a TPA for $500,000 annually and purchase stop-loss insurance with a $100,000 specific limit and a 125% aggregate limit. If claims total $8 million, the company saves $2 million compared to the budget, but if claims hit $12 million, stop-loss insurance covers the excess, limiting the employer’s liability.
Jerry- this is your plan for American healthcare? Self funded employer plans with third party administrators?
This ignores whole sectors of the population- our entire gig economy can’t use this solution. Contractors who are not employed can’t use this scheme. The unemployed can’t use this scheme.
Who is your intended audience? What are you selling?
Omg! My old friend! I love you!
No not a plan, just a non partisan breakdown of the mechanics.
No more, no less. 😘
We at Sentia Health are ready to take on new self-funded clients at $10/month with no brokers and no other TPA fees. Problem solved. Go read all about it right here on Substack. https://sentiahealth.substack.com
This guy is as fake news as it gets.
Clearly your have an axe to grind. Let's hear YOUR solution, Jerry.
Sentia Health is a company based in Pottsboro, Texas, founded in 2014 by M. Kirk Jennings. It develops electronic medical records (EMR) software to manage health insurance data for patients, aiming to automate processes and reduce costs. The company offers a patient portal that analyzes checkup data and provides health prescriptions. It operates as an unfunded EHR platform with reported revenue of $5.6 million but no listed employees.
(Note: Sentia Health is distinct from Sentia Medical Sciences, which focuses on peptide therapeutics, and Sentia Healthcare, which manages primary care businesses in Australia.)
So yes, Jerry, this is a thing, and you don't know what you're talking about particularly with your TPA crap. Please refrain from commenting on my posts any more, you aren't qualified to even understand what is going on.
Still didn’t answer any of my questions.
And I understand exactly, been developing software and solutions in this space for 20+ years.
I’ll put the 60m+ lives that have passed through my solutions up against your unfunded 5k BS any day of the week.
You can't do what I can do.
You clearly can't even understand what I do.
UHC has $400.3 B in revenue last year, are they doing it right?
No Jerry, you are closed minded and can't even drink when led to the water. this is the very definition of ignorance.
Your TPA gyrations are just more of the same, and perpetuating the processes that I have automated and not only ARE NOT WORKING, but MURDERING PEOPLE, through lack of access and lack of affordability.
No as stated earlier, I am tired of your trolling and willful, hateful ignorance.
Cease and desist.
I SAID GOOD DAY, SIR.
Please don't think you're not part of the problem.
Respectfully, you don't know what you are talking about. I am not only not part of the problem, but I am also the only viable solution. If you have a different opinion, I am open to hear it, but you are dead, murderously, wrong.
go ahead, tell me why I am the problem.
In fact, here is my solution:
Sentia has automated the entire health insurance process. We provide the EMR to practices, price the procedures 50% ABOVE Medicare, and pay for work performed in real time.
This eliminates medical coding, insurance networks, adjudication, delays, denials, rate negotiation, sales/brokers/agents, the cost of a third party EMR, skyscrapers in every major city in the US, and the hundreds of thousands of employees that work at the insurance company that you, as the insured, pay for.
For this service we charge $10 per month plus the actual cost of the risk (and stop loss/reinsurance). That alone should cut over 50% of the cost.
Further, we offer patient education based on the results of their lab tests. This happens automatically. When they read it, they get a small discount. When they follow it and get healthier, they get a large discount. This is scientific measurement and based on bloodwork. This gives the system 'teeth' by incentivizing healthy living. Then we start getting back some of the 84% spent on behavior based, chronic disease. Getting us down to the OECD average will save $1.34 trillion, or an additional 25%.
In total that would save us 75+%.
We have this system in prototype.
Lies.
Literally nobody in the industry has heard of this guy or his claims (no pun intended)
Really Jerry? Do you even understand what I'm talking about?
Not only do I understand the fantasy you are pitching.
I know the actual mechanics.
90m lives and counting over here.
More than 1/2 of all adjudicated claims over here.
What’s your count Einstein?
If you're so successful, why are we still taking about this? Clearly you've solved the problem. Not too bright are you? This is the only valid solution proposed anywhere. Tell me why I'm wrong, troll.
So why have employers allowed this to happen??
Because for profit private insurance corporations crooked lobbyists designed all this confusion.
Two of the dumbest comments ever. Read my post about the actual facts a little further down.