ASG Perspectives

SPOTLIGHT ON: Brown and Brown of Pennsylvania

Thursday, February 21, 2019

Brown and Brown of Pennsylvania is an established national brokerage that continues to thrive via a business model that provides all the resources and advantages of a major enterprise, yet allows individual offices to operate on a local level.

According to Bill Shoemaker, benefits sales rep for the Mechanicsburg office in southern Pennsylvania, this means that each office is given the latitude to respond to—and accommodate—employer trends unique to their particular region.

As the sixth largest brokerage in the country, Brown and Brown has more than 8,000 employees in 200 offices nationwide. Brown and Brown of Pennsylvania is considered a profit center for the three locations that work together in the region: Philadelphia, Conshohocken, and Mechanicsburg.

“The offices are decentralized, meaning we work locally—and we truly do work that way, but we are able to leverage Brown and Brown national programs,” Bill explains. “So you could have a stop-loss carrier like ASG working with three Brown and Brown offices, which is great because we are communicating constantly and can see that any time one office excels at something, we have an opportunity to do more to leverage that model.”

Bill, who works primarily in the 50-plus employee market, partners with employers in his region to write primarily traditional, self-funded plans. “That’s the sweetheart spot and the majority of how we work with ASG,” he notes.

Trends Impacting Employer Options

In his position, Bill is able to keep his finger on the pulse of key marketplace trends. One emerging issue he points to has to do with employers, especially those in the manufacturing space, who are struggling to simply hire qualified employees.

“Central Pennsylvania is heavy blue-collar manufacturing,” he says. “In our region alone, we’re looking at one out of 10 candidates who have potential for an interview—and yet we hear from other Brown and Brown offices that it’s hard to find younger help who are skilled with their hands or have a trade.”

How this relates to brokering the right plan hinges on the swing to self-insured for smaller employers. Bill points out that self-funding is becoming more viable—even commonplace—for companies with fewer than 50 employees; however, stop-loss carriers are naturally more cautious about risk.

“Before, the process of writing a self-insured group was not as detailed as it is now,” he says. “The underwriting process today has to be more strict, in that employers and carriers have to make sure that employees are actually at work. If an employee goes out sick, or is out on an FLMA or another leave policy, all companies—especially if they’re stop-loss—should have a policy in place that will protect them if an employee is not working. If eligibility is not defined, it could result in a claim not being paid by the stop-loss carrier. You can’t assume any more.”

Responding to Industry Restructuring

Meanwhile, massive consolidations within the health care system are also impacting communities. “We’re going through a lot of change in our market, with large carriers and health systems consolidating,” says Bill. “Of the 150+ general acute hospitals in Pennsylvania, only about 25 remain independent.

"Again, that changes the landscape of healthcare because you have different pricing mechanisms: whereas the cost of services in regional facilities was previously relatively cheap, now you’ve got the small hospital paying inner-city prices. There’s a lot of struggle, and the carriers have to change to navigate the additional layers.

Ongoing Challenges Mean Stronger Partnerships

In such an ever-changing climate, Bill says he values being a long-time ASG partner more than ever.

He points out that one of our core values—making the ASG underwriting team available to all broker and TPA partners—“is simply good business. We get to talk to them, and tell them the whole story behind this employer or that one. With ASG, we know they’re going to honor the contracts and pay the claims timely, because they’re just good people and we trust them.”


For more information, please visit Brown and Brown of Pennsylvania online.

On-Call with Sara Winand, RN: Rates for Air Ambulance Services Taking Off

Thursday, August 30, 2018



A recent issue of MyHealthGuide newsletter has put the spotlight on air ambulance regulation. In fact, the Health Care Administrators Association (HCAA) and Society of Professional Benefit Administrators (SPBA) recently initiated a targeted letter-writing campaign focuses on rising air ambulance transportation costs for self-funded health plans.


Without reform, America’s families, health care providers and the self-funded community face an increasing and often conflicting set of rules and regulations that fail to provide any semblance of financial certainty when life-saving air ambulance services are employed.



Air ambulances are typically covered by health insurance if determined to be medically necessary, and if the service is limited to the nearest appropriate medical facility. Fees are generally not covered if the air ambulance is used solely for convenience. Almost all air ambulance services are out of network, and since the service must typically be arranged under urgent circumstances,any pre-service negotiation is rarely an option.

At ASG, we’ve seen first-hand instances in which air ambulance charges have skyrocketed into outrageous dollar amounts, especially when used in urgent situations and provided by non-network vendors, oftentimes without precertification. Many times a deposit is requested from the patient/family and without a signed negotiation the member is balanced billed.

For example, we recently worked with a claimant who had an accident in Georgia and was hospitalized there, but needed a specialized rehab facility for recovery. We soon learned there are only fourteen such facilities in the country; the closest location was quoting a three-week waiting period; and due to the woman’s condition, air transport was the only option to get the claimant to any of the other thirteen. On top of these obstacles, the employer group’s plan did not require a precertification for the service.

The claimant was ultimately transported from Atlanta to a rehab center in Chicago. The air ambulance bill: $258,000. Thankfully we were able to negotiate the claim to $136,000, even though the air ambulance company was pushing for immediate payment.

These numbers are not unexpected. A recent study conducted by the Montana Legislature broke down air ambulance costs into two main parts: liftoff fees and per-mile charges. While the former ranges between $8,500 to $15,200, the latter can be anywhere from $26 to $133 per mile. These variable charges are based on distance and staffing needed for the transport.

We and others in our industry are keeping a close eye on Sentinel Air Medical Alliance, an alliance of healthcare payors established in response to the rapid escalation of air medical transport rates. Sentinel's goal is to provide solutions for effectively controlling rates and ensuring proper utilization of air transport services. The alliance's areas of focus include prior authorization for air ambulance services, medical review of transport claims, claim negotiating and repricing, and consulting services to help healthcare payors develop strategies to control air ambulance costs.

Global Emergency Services provided by Assist America are included with every ASG sold stop loss policy. These services are a supplement to the health plan but it is imperative to contact them to make arrangements such as air ambulance as they cannot reimburse for arrangements made by another party. For more information on Global Emergency Services go to



Spotlight on: Significa Benefit Services

Thursday, July 19, 2018

The more our ASG team does business with Lancaster, Penn.-based TPA Significa Benefit Services, the more we marvel at the value of a true partnership.

We first began working with Significa this past winter when Sales Executive Steve Shirk came to us with an opportunity to underwrite an employer group that presented several unusual cases, yet required timely coverage.

He recalls, “Time was of the essence and there was some pricing the broker wanted—in a level-funded format—so we worked around these things and ultimately, were able to move forward in a way that we all felt benefitted our customer.”

Get to Know Significa

Over the past months, it’s become clear that the 30-year-old firm shares more than a few core values with us at ASG.

For one, Regional Sales Director David O’Shea David notes that “as a TPA, we’re closer to the customer—we understand the customer’s needs. And that translates into our philosophy that the plan should be customized to fit the group, not the other way around.”

Transparency is key to achieving this end. “Without transparency, a business doesn’t know what to do to get control of its healthcare costs,” he explains. “By having access to claims data, and understanding the usage in that employer’s population, it helps us to design that plan in a way that helps control costs.”

Steve notes, “When we understand the customer, we understand what kinds of carriers and programs we want to bring to the program. Telemedicine programs, bringing in a fiduciary group—we’re tailoring the administration of that plan to meet the customer’s very specific needs.”

The second key is managing claims costs. David points out, “In our world, we’re auditing the emergency room client, we’re monitoring the surgical claims—we’re constantly looking for savings for the customer by managing the risks on a regular basis.”

Lastly, transparency—often a tricky achievement in our line of business, but key to proactively managing costs by managing care. At Significa, says Steve, “We have a robust claim reporting tool. We’re understanding the usage in our groups’ populations. After nine months or so we understand what the population is doing, and at that point, we can make changes to the plan.

“For example, when we see high utilization, we know the plan design is wrong. We want the employer to begin to get some control over costs—so we are able to reduce fourth, fifth, or sixth-year costs through a proactive approach to managing costs, managing care, and providing satisfying health benefits.”

The result of this diligence: knowledgeable employers and happy employees. “We find that once the employers see that full transparency, they’re able to make good decisions about managing healthcare costs effectively,” says David.

A Hands-On Approach

Significa also maintains relationships with vendors that the firm can match with the unique needs of employer groups. Steve explains, “By farming the data and understanding what’s going on, we can bring the right vendor to the table—and then we can control expense and enhance the experience with that customer.”

Significa is applying that model and differentiating itself with a third key partner: brokers. Specifically, by building consortiums, customers can buy in as participants, allowing Significa and its broker partners to grow business together.

“The small employer with 30 lives, 50 lives—they don’t have a lot of negotiating power. But in a consortium with thousands of lives that we can negotiate on their behalf, they now have the power of a large employer with the ability to negotiate insurance costs while spreading risks among several groups.”

Recognized for Experience and Caring

Here at ASG, we’ve often heard about the accolades Significa receives on a regular basis for its highly experienced claims professionals and dedication to customer service. “I think we bring a very good, experienced package with compassion and understanding about how we can assist our customers in managing risk,” notes Steve. “Being able to make recommendations, prove those recommendations to the customer, then implement those recommendations and measure those successes in subsequent years truly sets us apart.”

We value our relationship with Significa and look forward to many years of mutual success and growth!


SPOTLIGHT ON: INTERLINK COE Networks & Programs—Proactively Managing Plan Expenses

Monday, February 05, 2018


There’s a rapidly growing company in Hillsboro, OR, that’s been around for 23 years and is currently on the brink of changing the world.

Well, the world of cancer care management—which could prove to be monumental for all of us in the healthcare insurance industry.

For over 23 years, INTERLINK COE Networks & Programs has provided transplant network services for reinsurance carriers, insurance companies, self-funded employers, and other managed care clients in the United States.

INTERLINK is an established Center of Excellence-based company that recognizes the value of ensuring geographic coverage of evidence-based care protocols for plans across the nation. Its Centers of Excellence network provides access to high-cost, low-frequency medical procedures used by health plans of a range of sizes.

The company was founded by John Van Dyke, a former PPO negotiator, in 1995. In 2010, INTERLINK saw an opportunity to work with reinsurers to develop targeted cancer care management programs into the Centers of Excellence model.

INTERLINK’s CancerCARE program extends the firm’s Center of Excellence networks with specialized cancer case management nurses who provide consultative support for members looking to choose providers and seek treatments. Targeted cancer benefit language for employer plans is also included at no cost.

“Cancer is the number one employer-paid stop-loss deductible; number one reinsurer reimbursed claim at all levels; and also the number one cause of bankruptcy for members who are covered,” notes Van Dyke.

During a time when health plan premiums have increased 7% to 9% per year, the cost of cancer treatment has jumped an average of 20%. Van Dyke adds that health plans have no control over the frequency of cancer diagnoses, but can influence care quality with benefit incentives and definitions when inserted in the plan document.

However, he believes, there is an opportunity to control costs and increase optimal member outcomes, simply through improved quality of treatment. Better treatment translates into minimized complications and risk of reoccurrence—and ultimately, lower plan costs.

“Our CancerCARE program, from a plan level in managing cancer, is the number one investment that a plan could make to manage their members’ cancer care,” he says.

In 2018, the company CEO estimates the expected frequency of transplants will be 14.66 per 100,000 insured members; and of those 14.6 forecasted transplants, nearly half (6.0 of 14.66) will be for a cancer-related diagnoses.

“With benefit caps removed, a single poor outcome transplant can now cost the plan many millions,” says Van Dyke, “but if you put the CancerCARE benefit language in your plan, you could identify 41% of your transplant cases proactively. With this early notice, you can better manage your expenses within the plan."

Taking Risk Management to the Next Level

“Once you put CancerCARE in your plan, you’re already managing your transplant risk.”

–John Van Dyke, CEO

INTERLINK’s TransplantCARE and CancerCARE programs are based on performance narrowed concepts through networks that are built on “value-driven principles, the best providers, and timing for the best cost,” says Van Dyke. “When you performance narrow with INTERLINK, and outcome improving your very low-frequency, high-cost medical procedures, we’re not disrupting care, but improving member decision quality.”

The Data Tell the Story

The INTERLINK performance model addresses all solid organ transplant programs. The data-accepting capabilities of the model was extended in 2017 to accept transplant outcome data for all transplant teams throughout the U.S.

“We’re looking at 25 of the most telling outcomes for all transplant teams,” explains Van Dyke. "Which identifies for us those transplant teams posting the best outcomes.”

That data, says Van Dyke, "comes to us risk-adjusted by transplant center and team—so we have the cleanest data set in healthcare to rank the lowest-rated to the number one outcome provider in the country.”

For example, should a covered member require a liver transplant, he explains, “INTERLINK’s narrow-performance network directs them to a facility where the surgical team is high-performance, high-competency. We’re looking for a great member outcome, which almost always comes with a lower cost.”

A New Era in Cancer Care Management

As Van Dyke continues to work with brokers, consultants and health plans of all types to incorporate the Centers of Excellence model to cancer treatment, he understands that the healthcare market can be slow to adapt to new concepts. Yet after nearly three decades working in the business, he is confident INTERLINK’s solution is about to have a significant impact.

“I see the cancer care and transplant programs as examples of today’s most important initiatives,” he says. “Our focus is on quality care, and the outcome of quality care is reduced price. So if healthcare moves on this pathway, I believe this is how we’re going to solve our healthcare crisis.”


On-Call with Sara Winand, RN — Let's Get Creative with Corporate Wellness

Thursday, January 04, 2018

Many wellness programs offer paid time off as a reward for completing certain ongoing tasks—like taking so many steps in a designated two-week period can earn an employee one hour of PTO. For example, Blue Cross Blue Shield South Carolina offers its Get in the Habit of Moving More Challenge to help employees move toward better health. We started looking into this trend, and discovered the following article from Benefits Broker Pro, which we thought would be of interest to any TPA or Broker looking to offer a new twist on corporate wellness.


Corporate wellness is having its moment 

A cloud has been hanging over the corporate wellness industry, in no small part due to an often-cited RAND study which shows wellness programs are having little to no effect on reducing employer health costs.

Findings like this spell bad news for wellness solutions, not to mention for the HR departments that have invested billions in them. Does this mean it’s time to throw in the towel? Hardly.

Reverting to business as usual isn’t a winning strategy. Chronic illness, health costs, and lost productivity are all on the rise. Companies that ignore these issues do so at their peril.

All of the above is why I believe in 2017 the wellness industry is having its moment. While the initial hype behind wellness has led to serious disillusionment, we are now at a pivotal turning point, where thoughtful approaches, as well as some hard-learned lessons, start leading to real results.

Lesson #1: Stop creeping out your employees

All too often, wellness programs alienate employees long before any progress can be made. This usually begins with the health risk assessment -- a deeply flawed but widely used tool. These impersonal assessments ask employees to answer invasive questions like, “How many times do you cry per week?”

Lesson #2: You can’t force employees into better health

If your employees believe they are being forced into a program or penalized for not participating, that new Fitbit you’ve rolled out can quickly look like a pair of handcuffs. It’s crucial instead to nudge employees into wanting to participate and be proactive in maintaining or improving their own health.

This level of trust and engagement will never happen in a program where employees feel berated for not losing enough weight or taking too few daily steps. Wellness programs must dig deeper to determine what employees want and what will motivate them to achieve long-term health goals.

It’s important to remember trust goes both ways. Allowing employees to opt-out if they aren’t ready is a leap of faith employers must be ready to take. The focus for these non-participants then becomes determining what they need to feel ready and capable of improving their health.

Sound like a lot of effort? It is. But the alternative is failure. A mandatory, punitive wellness program ultimately won’t create positive engagement or meaningful behavior change.

Gym stipends and other perks such as on-site yoga classes are great. Companies should absolutely offer them if it makes sense for their employees. But workout perks can’t be the final word in a wellness program. Social determinants of health should factor in, too.

If an employee is dealing with anxiety that makes getting out of bed a daily struggle, what good will a gym membership do them? In addition to exercise and nutrition components, a wellness program should fulfill behavioral health needs. Services such as stress management workshops, financial counseling, and substance abuse treatment can make a world of difference in the health of employees.

Lesson #4: Culture is king

What these lessons have in common is that they are all points to consider before rolling out a wellness program in the first place. To that point, there is no value in offering a program until leaders have a thorough understanding of their company’s culture.

I tend to view corporate culture as the iceberg that lives beneath the surface of any wellness program investment. Culture single-handedly determines how much ROI is observable at the top. Companies which lack strong cultures -- where employees feel valued, believe in their company mission, and trust peers and leadership alike -- will continue to see their investments in wellness sink, dragged down by internal dysfunction, fear and mistrust.

There’s no quick and easy way to make wellness programs work, but the right formula is simple. Successful programs accurately reflect employee health needs at the individual level, are built on solid work cultures, and engage employees in a spirit of co-creation. When these dynamics are in place, a wellness program is primed to provide useful, personalized solutions which lead to a healthy return on investment for employees and the company alike.


A Value-Based (and Very Smart) Approach to Partnerships

Thursday, June 29, 2017

It’s always gratifying to be called number one, and we were especially pleased when we came out on top of the list of preferred carriers for western Nebraska’s Regional Care, Inc. (RCI), an independent TPA.

That’s according to RCI’s Vice President of Sales Tom Applehans, who recently chatted with ASG about a number of steps the firm has been taking to provide more value to the marketplace.

“Our leadership team has taken a hard look at how we were interacting with our stop-loss partners. We felt that we maybe could do better if we worked a little bit closer with some of the carriers and the reps that had done the best job for us. So I surveyed the team and asked: of all the partners that we work with, who are the ones who are the most responsive, the most reliable on renewables, and so forth. ASG was a resounding number one on the list of responses from the team.”

He continues, “We like that ASG takes pride in their interpersonal relationships. The group gets along well with the team, and ASG is consistently competitive in its underwriting. You’ve also been reasonable in terms of medical underwriting and blocking in proposals. The biggest thing right now is finding partners that are reliable and that we like.”

That input prompted the RCI leadership team to green-light a preferred program within the company. While the program is “somewhat informal” at this point, its objective is to narrow the wide net of potential markets the company goes to for the bulk of its business.

This relationship-building aspect of our partnership translates into serious value for RCI, which serves over 200 clients with members in all 48 states from its headquarters in western Nebraska.

“What we’ve been explaining to our clients is that there is exposure if we aren’t selective and working closely with our stop-loss markets,” Tom notes. “So by taking this approach, we can do more business with vetted carriers, which reduces their exposure and improves our competitive position—it’s a way of managing risk and driving competitive pricing via consolidation and relationships, while still providing quality information and services. Rather than over-shop, we’re encouraging our people to simply do a better job working within defined markets.”

Tom points to the equal importance of bringing proactive solutions to existing and prospective clients. “It can be as simple as going back and looking at the network that’s in place, and taking the time to perform a discount analysis to uncover whether there’s an opportunity to improve pricing through a change,” he says.

The firm has also recently introduced telemedicine, and added a clinical program to help clients who have employers with high claims. Enhanced wellness and well-being programs (which include biometric screenings) and a new pharmacy program help RCI provide more thoughtful strategies while also controlling costs.

The goal in providing these tools, says Tom, is to enable RCI representatives to become trusted advisors with their clients. “And as we have those conversations, we’re working closer with our stop-loss partners so they have an idea of the direction we’re taking,” he says, adding that “if we can impact risk, that’s ultimately factored into the renewal and pricing on the front end.”

Response to the updates has been favorable among RCI clients. Tom notes the staff is also excited for the opportunity “to have those types of conversations, and try to get at underlying cost drivers rather than taking a more transactional approach to marketing.”

It’s all hands on deck at RCI headquarters, he adds. “We’ve been making some pretty sweeping changes over the past couple of years. It’s a work in progress, so every week we meet with our respective teams and leadership groups to try and constantly refine how we’re doing things internally and working with our clients. Everybody is being asked to find best in class solutions to address the kinds of problems our clients are facing. Historically, this company has had a very good reputation—as having great people, offering great service, etc.—so I think that we’re building on that, but also pushing the boundaries toward a high degree of excellence.”

Speaking for ASG, we are thrilled to be leading the charge with our valued partners!

Click here if you’d like to find out more about RCI.

Relationships: The Heart of Teamwork

Friday, May 12, 2017

Here at ASG, we frequently talk about relationships with our TPA and Broker partners. That’s because the interactions we have are incredibly important not only to our mutual business, but to ensuring we both offer the best possible services while striving to protect our employer groups’ interests.

In several instances, we also maintain important relationships with companies directly.

This is the case with Canon Virginia, Inc., a global manufacturer for Canon’s office and consumer products based in Newport News, Va.

Since 2004, we’ve worked in partnership with Phil Gilstrap, an Independent Broker, and Canon’s Benefits Administration group, led by Jackie Wall and Rhonda Bunn. Jackie and Rhonda administer coverage for the approximately 1,200 employees of Canon Virginia and a nearby subsidiary, all located in and around the Virginia Beach area.

Our relationship with Canon began when the company had been seeking a carrier change. ASG founding member Al Graffam happened to be the first Stop-Loss representative to respond with a complete presentation – and “the relationship has been a success since then,” notes Phil.

At the time, he recalls, the carrier that Canon had been working with seemed to have a philosophy based on looking at all clients equally. “If they had a pool that was bad, they just increased the rate on all players the same way,” he explains. “As a result, Canon was seeing tremendous cost increases on their policies. It seemed like the actuaries were looking at the numbers and saying, ‘Let’s just increase everybody.’”

ASG and Companion Life took a different stance. “Even without any longevity of experience with Canon, they still gave us some relevance when it came to our own loss ratio, and that was key,” says Phil. “Now that we’ve got 14 years in, we feel that ASG can really look at our medical claims and predict our needs. This holds rates down, and saves a ton of money. I crunched some numbers and determined that if we had stayed with the other carrier, based on the increases Canon had in its last year with them, by this time it would have cost Canon in the area of several million dollars.”

The value of this relationship has not been lost on Jackie, Canon Virginia’s Benefit Supervisor. “We know that ASG cares about Canon Virginia and we’re grateful to them for taking care of us,” she says. “It’s refreshing that whenever anything is needed, it’s no more than a phone call or e-mail away. I know I can talk to just about anybody at ASG and have the confidence that it’s being done right.”

Mutual Challenges and Goals

Rhonda, who works as Canon Virginia’s HR & PR Director, notes that like other employers throughout the country, an aging workforce has become a challenge that must be met head-on. “We’re all getting older, and so we’re dealing with things we haven’t had to deal with in the past,” she notes.

For example, 20 years ago the company had a younger workforce and covered more pregnancies, “whereas now it’s dealing more frequently with things like muscular skeletal issues,” says Rhonda.

On the flip side, notes Phil, “Canon is still hiring, and many of the people they’re hiring are young – but they too present a different set of issues. However, because Canon stays ahead of the curve and we’re working with a partner like ASG, the company is able to address trends as they come.”

The team points to the many preventative measures the company has implemented as proactive efforts to keep claims down. Examples include hiring a registered dietician and offering Weight Watchers on-site, both of which have been met with extremely positive reception among team members.

“We’re definitely in touch,” says Jackie. “We try to have that open relationship and have our members tell us what’s happening… what kind of environment would you like to see. They’re very comfortable coming up to HR and saying, ‘What doctor should I see?’ or ‘Can you explain this part of my policy?’ And we are here for them.”

In fact, she notes, Canon Virginia is especially proactive in communicating the economics of insurance coverage with its family members. “We tell them we’re self-funded, and we tell them what it is. We want them to understand their premiums are based on the rates that they pay. If they go unnecessarily not caring about staying in-network or not taking care of themselves, they know that what they do will impact their costs as well. We show them the numbers and they see what they contribute, and what we contribute, and they get it.”

Keeping these lines of communication open feeds into the overall culture at Canon Virginia, which Rhonda notes is based on caring about employees and vendors as a family. She sums up the company’s approach: “We want to work with people who understand our environment and treat us like family – who are responsive, and who customize, and pay attention to the details – and that’s what we get with ASG.” 

For more information about Canon Virginia, visit


On-Call with Sara Winand, RN – Pediatric Neuroblastoma: Wow!

Friday, January 27, 2017

Neuroblastoma is a tumor that develops from nerve tissue, most commonly in the adrenal glands, and affects mostly infants and young children. It is staged I-IV and categorized as low-risk, intermediate-risk and high risk.

– Children with low-risk disease can be treated with surgery, and a complete resection is usually achieved.

– Intermediate-risk disease treatment includes combined chemotherapy and surgical resection.

– For children with high-risk neuroblastoma, there have been substantial improvements with aggressive combination modalities. These generally include chemotherapy, surgical resection, high-dose chemotherapy with stem cell rescue, radiation therapy and biologic/immunologic therapy (e.g., Unituxin® (dinutuximab*)). These approaches have improved event-free survival, but unfortunately, many are at high risk for relapse of their disease.

Let me share a brief summary of two high-claim cases we have followed recently. In cases like these, it’s difficult to anticipate ongoing costs.



Imagine having a newborn just four months old diagnosed with stage IV neuroblastoma per exploratory laparotomy, liver biopsy and bone marrow biopsy. The chemo regimen required inpatient confinement, then another confinement for low blood counts. Two months later, after chemo was completed, they began stem cell harvesting in preparation for the planned autologous stem cell transplant. Scans showed residual tumor with incomplete response and the baby was admitted for excision of the residual tumor. High dose chemo and autologous stem cell transplant followed surgical recovery.


This young child unfortunately had suffered post stem cell transplant complications and required home TPN, but was eventually weaned off and able to undergo radiation to the liver and primary site. With reevaluation and family conference, the decision was made to proceed with immunotherapy treatment regime with Unituxin® (dinutuximab*). This required inpatient care for the infusion therapy and paid claims varied from $65,000 to $175,000 per admit. Post treatment complications required acute care, but by August, the medical team was able to report no recurrence or progression!

The outcome was the good news, thanks to the fact there was a global transplant policy that covered the autologous stem cell transplant.

The bad news was the claims incurred.

– In 2015, the seven months of treatment (excluding the stem cell transplant, which was covered by the global contract) billed charges were $763,196. The TPA paid $341,644 from ground up.

– In 2016, with six months of treatment, billed charges were $1.6 million and the TPA paid $750,000.



This seven-year-old was diagnosed with high-risk neuroblastoma in mid-summer 2015 and began treatment with induction chemo, requiring multiple hospital admits followed by surgical resection/adrenalectomy with lymph node dissection in late November. A tandem autologous stem cell transplant after recovery was also planned, with an Optum transplant contract placed with Boston Children’s Hospital.


The child was admitted in March 2016 for the first stem cell transplant (paid $280,000) and readmitted the next month for the second stem cell transplant (paid $203,000). Post-transplant chemo of five cycles began in July, requiring four to five days of inpatient care. She was hospitalized for 18 days in August (paid $140,000) with hypertension and thrombotic microangiopathy (clots in small blood vessels) and has been treated with the monoclonal antibody Soliris® (eculizumab). Other complications required inpatient care and intensive outpatient care, and the eculizumab treatments remain ongoing every two weeks ($35,000 to $40,000 per treatment).

– Claims in 2015 billed $825,000 and the TPA paid $425,000.

– Claims in 2016 billed $2,176,303 and the TPA paid $1.8 million. Claims will be ongoing in 2017.

Although treatment outcomes are dependent on tumor characteristics, age and extents of metastasis, it is interesting to note that infants less than one year of age have a better survival rate than older children.


*On March 10, 2015 the U.S. Food and Drug Administration (FDA) approved dinutuximab, which is a monoclonal antibody against GD2, for use in the treatment of high-risk neuroblastoma. It was approved as part of a multimodality regimen, including surgery, chemotherapy, and radiation therapy, for patients who have achieved at least a partial response to prior first-line multiagent. It is indicated in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA) for pediatric patients with high-risk neuroblastoma.


Advancing Health — and a Healthy ROI

Saturday, September 17, 2016

From medical plans and health administration to the latest online benefit management tools, our partner POMCO offers a wide variety of solutions built to advance member health while containing employer costs.

The Syracuse, N.Y.-based TPA has been a valued ASG partner for more than two years, and we’ve found a great common ground in providing value through collaborative high-touch services.

Mansi Johri Gupta, POMCO’s Manager, Business Development Analytics, recently shared her perspective on how POMCO sets itself apart in the increasingly complex benefits administration industry.

First, she explained, “We try to align ourselves with clients who have a strategy of meeting goals and high expectations with regard to service. Whenever we talk with someone about their health or their business, it’s really important that our clients know we are working together to find the best solutions.”

Specializing in Client Excellence

POMCO has developed a specialty in municipalities and labor groups due to the high level of flexibility the company is able to offer through its self-funded solutions.

For example, municipality or labor unions may work under annual contracts that require returning to the bargaining table in order to make changes. By offering fully customized and highly flexible options, POMCO is able to ensure clients get the most from their health benefit investments.

Mansi added that this specialty further aligns with collective bargaining groups, who “really look to us to help manage those budgets without raising co-pays or other costs. At the end of the day, it’s all about saving costs: They have a budget at the beginning of the year, and they want to stay within that budget. We help them meet that goal.”

POMCO also works closely with a high concentration of both private- and public-sector hospital and healthcare centers; the company works with several university clients as well.

Industry Trends and How POMCO Adapts

Mansi touched briefly on the impact the ACA has had on self-funding since being implemented in 2010.

She said “For groups looking at high deductible health plans, or plan design strategies that mitigate costs, POMCO has a pretty aggressive cost containment approach where we look at every possible way to reduce costs. We look at case management, different types of ancillary services – all possible ways to help our clients meet their goals. Our focus is on how we can help them meet their budget without shifting costs.”

Additionally, POMCO is actively pursuing promising opportunities by working strategically with related industry partners to offer employer groups a menu of more than traditional benefit plan designs.

The company is also staying competitive relative to the technology it can offer both clients and members. “We know that healthcare is advancing with technology, and meeting the expectations of clients who are living in a digital forward space, right now, is critical,” she said.

Lastly, Mansi noted that POMCO currently has a very aggressive growth strategy for this year that involves building on its client base in California and continuing expansion into the west.

“We’ve been very successful since we started this expansion nearly three years ago, and we hope to bring in more clients from targeted states as we continue to grow,” she added.

We’re looking forward to continuing to build on our relationship with POMCO to help companies contain costs and continue their good work.

Visit to learn more about this valued partner’s benefit, risk management, and business process outsourcing solutions.


Mental Health & Substance Use Disorder – Who’s Abusing Who?

Wednesday, July 27, 2016

by Sara Winand, RN, Director of Medical Management

The Mental Health Parity and Addiction Equity Act of 2008, which went into effect January 1, 2010 has changed the way Mental Health and Substance Use Disorders are viewed and paid by employer groups.

Cumulatively, a series of changes and trends have been having a serious impact on our mutual abilities to underwrite a competitive policy that works to support our employer groups’ businesses – not cripple their budgets.

The impact of Health Care Reform is extensive. The act mandates:

  • – No annual dollar limits
  • – No lifetime maximums
  • – No annual limits on number of days or visits
  • – Coverage extended to dependents up to age 26

We are now seeing covered individuals seek treatment for Substance Abuse more and more frequently, with costs for treatment ranging from $150,000 to $300,000 – for a single year.

In fact, in the six years since the Act passed, the group for which we’ve seen a growing trend in high claims is 16- to 26-year-olds! This age group is the highest risk category for relapse and ongoing charges, and has become a financial liability to plans and excess carriers across the U.S.

Why? Here are a few trends that may answer that question:

  • – Mental Health (which includes Substance Use Disorder) is now a covered benefit just like any other illness.
  • – Although many facilities have been out of network in the past, we are seeing a trend for now in-network claims for Substance Use.
  • – Facilities are now outsourcing labs, so urine drug screens are billed separately and frequently (many times daily) and often cost as much as the facilities’ daily charges.
  • – Facilities are billing incrementally, meaning these charges are flying under the radar and are not readily detected as a potential LARGE claim.
  • – Many plans only require precertification for inpatient acute care and can go unmonitored when the claimant steps down to Residential, Partial Hospitalization, IOP (Intensive Outpatient) then to OP.
  • – Facilities are typically located out of state; many resemble a resort: They are lined with palm trees, feature seascape landscaping, and offer 4-star cuisine, recreation and exercise programs which oftentimes include yoga, horseback riding, spa therapy, and more.
  • – Many websites feature logos of PPO networks but are not actually affiliated with these or any network.

As partners invested in protecting our employer groups’ interests, it’s important that we do what we can to stop the bleeding. Try asking the following questions when you see claims related to Mental Health or Substance Use Disorder treatment:

  • 1.Is this person’s treatment court-ordered?
  • 2.How is this treatment being certified for medical necessity?
  • 3.Is the facility licensed for the diagnosis and services it is billing for?
  • 4.Does the facility bill for IOP more than five days a week?
  • 5.Should I have claims and the medical records sent out for review before paying the claim and submitting to stop-loss? This is highly recommended.

With the lethal cocktail of health care reform, lack of financial limits, and mandatory coverage to age 26, it is anticipated that Mental Health and Substance Use Disorder claims will only become more prevalent.

Please contact us at and let’s work together to try to reduce the financial risk these trends can pose to our employer groups.



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