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How to Beat Fully-Insured Employer Health Plans That Deny Care

December 27, 2023

Looming Employer Litigation: Is J&J the Canary in the Coal Mine?

February 19, 2024

When Did a Trip to the Hospital Become an Adventurous “Journey?”

December 6, 2023

Escape the Cost Death Spiral by Funding Your Health Plan the Right Way

June 21, 2024

Vitori Expands Capacity with Acquisition of Flume TPA Operations

October 11, 2023

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Americans Struggle to Pay for Health Care. Vitori Can Help.

Vitori Health on October 30, 2023

< 1 minute

The results from the Commonwealth Fund 2023 Health Care Affordability Survey are grim. American consumers continue to struggle with unsustainably high costs and inadequate coverage. Unsurprisingly, nearly 40% forgo or delay needed care and don’t fill prescriptions to avoid risking financial ruin.

This includes individuals with employer-sponsored health plans, 43% of whom said it was “very or somewhat difficult to afford their health care.” Insurance coverage didn’t prevent people from incurring medical debt. Additionally, 30% of covered employees report paying off debt from medical or dental care over time, especially for treatment of an ongoing health condition.

The survey concludes with suggestions for making healthcare more affordable, including lowering deductibles and out-of-pocket costs. A comprehensive, member-focused health plan from Vitori Health goes even further by shrinking total medical and Rx cost by 30% and adding these free benefits wrapped in a remarkable member support experience.

  • No-cost telemedicine, including mental health services
  • $0 Surgeons of Excellence program
  • Rx financial assistance and no-cost specialty medications
  • Advocacy for securing hospital financial assistance
  • No member liability for balance billing

Plan sponsors seeking long-term cost stability and security will appreciate Vitori Vantage, our industry-first, level-funded health plan that delivers 36 months of fixed premiums for stable cash flow and predictable budgeting.

By dropping legacy insurance carriers and outdated PBMs, plan sponsors can substantially improve employee health and financial well-being and help bring needed change to the US healthcare industry.

Vitori Expands Capacity with Acquisition of Flume TPA Operations

Vitori Health on October 11, 2023

1 minute

Vitori Health is thrilled to announce its acquisition of Flume Health’s third-party administrator (TPA) operations. This strategic purchase complements Vitori’s significant growth and adds talented new team members, further enabling it to deliver industry-leading health plans and remarkable member services.

Like Vitori, Flume is recognized for its modern architecture and leading-edge capabilities. This highly complementary union furthers Vitori’s commitment to delivering transparent, cost-reducing, value-enhancing, member-first healthcare solutions and services to its clients.

Key highlights of acquiring Flume’s TPA operations include:

  • Increased Capacity | Expands Vitori’s operational capacity to spark continued growth and meet market demand through the acquisition of Flume TPA team members, TPA clients, and administration technology.
  • Enhanced Technology | Augments Vitori’s existing infrastructure to deliver innovative healthcare solutions and administrative efficiencies.
  • Administrative Agility | Strengthens Vitori’s administrative flexibility and its ability to offer more tailored and customized solutions to its clients.

Tim O’Brien, Vitori Health CEO, describes the acquisition of Flume’s TPA operations as “an ideal fit to bolster our strengths and fuel our continued, quality-focused expansion.” Further, it “aligns with our strategic market orientation and rapid growth” and “complements our existing payer services and plan administration capabilities as well as adding significant talent to our existing experienced team.”

The founder & CEO of Flume Health, Cédric Kovacs-Johnson, is equally energized by Vitori’s acquisition of its TPA operations because of shared values and a shared “mission to deliver modern health plan experiences.” He adds, “This decision allows Flume to focus on software products, including our data exchange platform called Relay, solving the critical interoperability challenges in the payer ecosystem.”

Vitori Health is known for its dedication to improving healthcare costs and outcomes, and to delivering exceptional customer experiences. The acquisition of Flume’s TPA operations is a testament to its vision to be at the forefront of healthcare innovation.

Vitori Health Announces Insurance Industry’s First 3-Year Level Premium Health Plan

Vitori Health on September 6, 2023

2 min

KANSAS CITY, Mo., August 29, 2023 — Vitori Health, a national precision-built health plan solution that provides a high-performing alternative for mid-market employers and their employees, announced today its Vitori Vantage product, an industry first 36-Month Level Premium Plan.

As an innovator in the health insurance industry, Vitori Health is thrilled to announce this groundbreaking new product. Vitori Vantage is a revolutionary offering that will transform the marketplace through exceptional value for employers and employees nationwide with three (3) full years of unchanging health plan premiums.

This 3-Year Level Premium Plan represents the next stage of ingenuity and innovation for which Vitori is known. It leverages proprietary financial engineering with unique features and benefits to combat continually rising annual health plan costs.

“We are very excited to offer the Vitori Vantage product,” stated Tim O’Brien, Vitori CEO. “It is a game changer for employers seeking multi-year health plan premium stability for their business and for their employees. Vitori Vantage is the only plan that locks in annual premiums for 36 months, eliminating cost increases that are trending at 10% or more annually. The launch of our Vitori Vantage product upholds our history of meeting market demands for innovative products that drive down the cost of healthcare while improving employee benefits and support.”

Unique features of the Vitori Vantage Plan:

  • Complete all-in rate lock for 3 full years
  • No increase in administrative, claims, or reinsurance expenses for three (3) years
  • Renewable for additional 3-year term
  • Surplus premium available for renewal or pay out

Enhanced member benefits include:

  • Full-service concierge provides plan members enhanced personal service
  • No balance billing liability
  • $0 PCP visits
  • $0 generic Rx and $0 specialty Rx with financial assistance and lower cost drug sourcing
  • $0 virtual care for physical and behavioral health
  • $0 for surgeons of excellence elective procedures

Vitori’s Vantage 3-Year Level Premium Plan is available to select brokers / advisors and employer organizations. Additional information about Vitori Health and the Vantage Plan is available on the Vitori website.

###

About Vitori Health

Vitori Health is a comprehensive next-generation health plan solution focused on expense reduction and increased value through evidence-driven design, payment integrity controls, better member value, and guaranteed results. Vitori’s success is anchored in its ability to drive 30% savings by addressing legacy health insurance conflicts of interest, service, and cost control challenges while delivering an exceptional member experience and an unmatched savings guarantee.

Built from the ground up, Vitori leverages proprietary technology and business processes to seamlessly integrate custom-designed features, including concierge member support and advocacy, unique medical payment controls, preferred surgical arrangements, optimized pharmacy pricing, and employer contracting without hidden fees. The result is a high-performance health plan that is significantly less expensive for plan sponsors and employees.

Website | vitorihealth.com

LinkedIn | https://www.linkedin.com/company/vitori-health/

Media Contact | Neil Quinn | nquinn@vitorihealth.com | 216-284-1862

Privacy or Cover-up? Hiding Behind HIPAA to Inflate Insurance Premiums

Vitori Health on May 7, 2023

< 1 minuteWhen the HIPAA Privacy Rule was enacted in 1996, its intent was to protect personal medical records and health information. This goal has since been weaponized by legacy health insurance carriers who withhold data from fully-insured plan sponsors to obscure their justification for higher premiums.

A recent article explains how smaller employers “only receive meager large-claims data at the end of the year. You will not get month-to-month claims versus premium information. The stated reason: carriers are concerned that if they give you too much specific detail about your employees’ health and claim activity, you may be able to discern who has what condition. This, the logic goes, violates HIPAA. The smaller your population, the greater this risk. … This argument is absurd, but it has been the reality in the industry for twenty years.”

There is another, perhaps more insidious, reason for not sharing claims data: to keep employers from escaping the prison of the legacy carriers’ fully-insured health plan. Claims data are the “receipts” for an employer’s plan expenditures with healthcare providers. Without this vital information, fully-insured employers cannot get the stop-loss insurance that enables self-insurance and the cost control and plan design freedom that it brings.

Privacy and transparency are not mutually exclusive. Both can be attained with a modern, self-funded health plan that eliminates the conflicts of interest inherent in fully-insured legacy plans.

By choosing a health plan administrator like Vitori Health, employers can experience freedom of choice, total transparency, and unfettered access to claims data supported by a proven cost and risk suppression platform. Employees will receive better benefits at a lower cost and a remarkable member experience.

Insulin Cap May Drive PBMs to Keep Profits by Hiking Employer Premiums

Vitori Health on April 28, 2023

< 1 minuteMedicare patients cheered when the Inflation Reduction Act capped monthly insulin costs at $35. Then drug manufacturers controlling 90% of the market set this $35 cap for everyone by bypassing the PBM middlemen. To protect their black box of profits, insiders expect PBMs to raise employer premiums.

Consider how much money is at stake. Patients who paid over $1,000 per month for insulin in 2018 are now paying only $35 in 2023. And despite slashing insulin costs by 70%, pharmaceutical companies will still profit handsomely. It’s a win-win for all stakeholders except the PBMs.

This huge gap represents the “60% or 70% of fees” taken by PBMs, who act as intermediaries between drug manufacturers and pharmacies in the supply chain. These fees are a driving force behind the rise in prescription drug costs. Such predatory business practices are all about profits, so a loss here must be offset by a gain somewhere else. Next target, employers.

Employers can fight back and save money by axing their PBM and working with a modern health plan that delivers an ethically-grounded pharmacy program and formulary based on science and clinical value with advanced cost-plus pricing technology for net lowest cost results. Transparent pharmacy services administration ensures that what’s paid at the pharmacy is what the employer plan sponsor pays and 100% of rebates paid monthly.

It’s time to eliminate the dubious fees and questionable practices that raise costs for employers and their members.

How Can Employers Get Fair Hospital Pricing?

Vitori Health on April 13, 2023

2 minHealthcare costs are spiking to record levels and burdening the nation’s employers. Significant portions of premium dollars pay for inpatient hospital services, with employers paying 200% or more of Medicare prices. “Plan sponsors as plan fiduciaries have to take action. They can’t just stand for it.”

So says Michael Thompson, president and chief executive officer of the National Alliance of Healthcare Purchaser Coalitions (National Alliance), whose playbook supports employers’ claims that hospital prices are unreasonable and unsustainable. It also urges employers to take more responsibility for negotiations.

While very large employers might have the wherewithal to navigate reimbursement discussions with hospitals and health systems, it’s like asking patients to be cost-effective healthcare shoppers in an opaque and foreign healthcare economy: much easier said than done.

The legacy health insurance carriers have done almost nothing to address hospital cost relief for decades. In fact, BUCA contracts with hospitals perpetuate the cost escalation, allowing hospitals to charge whatever they want with little oversight while insurance carrier profits increase along with rising hospital charges.

Reference-based pricing (RBP) is often touted as an alternative because it caps costs at a negotiated percentage above the baseline Medicare price. The downside is that RBP’s overly simplistic reimbursement method and combative stance with providers routinely results in contested claims payments. Employees bear the brunt of this friction with balance bills that increase their medical costs and create financial uncertainty.

Achieving Fair Pricing with Fair Market Payment™

Vitori Health removes the unrealistic expectation of hospital price negotiation from employers and their health plan participants with its exclusive Fair Market Payment™ algorithm that determines appropriate claim payments honored by providers without friction. This unique and sophisticated approach drives significant health plan savings while delivering an exceptional member experience.

A nationwide analysis of plan performance reveals that:

  • 98.8% of Vitori FMP reimbursements are paid by providers without question. Claims with extenuating clinical circumstances may warrant an easily administered reimbursement adjustment. BUCA insurers and RBP plans regularly deny and delay a much larger percentage of claims, frustrating providers.
  • Less than 0.24% of Vitori claims have an unexpected member bill compared to BUCA and RBP plans, which have 10-40 times higher rate of unexpected member billing.

A modern, member-first health plan with advanced technology can effectively counteract today’s skyrocketing hospital and healthcare costs. Employers can realize 30% savings with industry-leading plan advantages and unprecedented 80+ Net Promoter member satisfaction scores.

3x3x3 Interview Captures Vitori’s Outstanding Value Proposition

Vitori Health on April 10, 2023

< 1 minuteWe are excited to share that Neil Quinn, Chief Strategy Officer at Vitori Health, was interviewed by Chris Fisher to create a BenefitsAlly 3x3x3 video.

In 3x3x3 interviews, innovative solution providers answer three questions of interest to benefit advisers using three slides in under three minutes. Neil provides quick yet comprehensive answers to these questions:

1. What is Vitori Health?

2. How is Vitori Health different?

3. Who is a good fit for Vitori Health?

>>WATCH THE VIDEO

Benefit consultants can learn more about the advantages of a modern health plan from Vitori Health and Vitori Vantage, the industry’s first 3-year level-premium plan that breaks the cycle of annual renewal cost increases.

– – – – – – – – – – – – – – – – – – – –

Chris Fisher is the founder of BenefitsAlly. Their mission is to discover programs that are innovative, solve a problem, and have a proven track record of success. They share these great solutions with benefits consultants so they can stay competitive by bringing essential solutions to employers before their competition does.

Patients=$0. Insurers=Millions. How to Boost Profits by Denying Claims.

Vitori Health on April 4, 2023

2 minMedical directors adjudicating claims are supposed to examine patient records, review coverage policies, and use their expertise to approve or deny claims. But at Cigna, they spend only 1.2 seconds on each case and instantly reject millions of claims without even opening the file.

This unfair review process, known as PXDX, is designed to boost profits by reducing claims processing costs, denying coverage, and avoiding payment of health care claims. The volume is staggering. According to a ProPublica exposé, “Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method.”

One former executive describes PXDX as “…a system built to deny claims.” Another, who helped conceive the program, questioned at the time whether such speedy denials satisfied the law or fell into a gray zone. “We sent the idea to legal, and they sent it back saying it was OK.”

It may be legal, but it’s certainly not ethical. The practice leaves patients with unexpected bills and encourages health care avoidance for services that should be covered by any decent employee health plan.

Ironically, Cigna has stated that its PXDX system does not prevent a patient from receiving care — it only decides when the insurer won’t pay: “Reviews occur after the service has been provided to the patient and does not result in any denials of care.”

Employers can circumvent this insanity by avoiding monopoly insurance carriers that prioritize profits over people. The ideal solution is a self-funded plan from a modern health plan plan administrator. Fair Market Payment™ (FMP), which is offered exclusively by Vitori Health, establishes fair and acceptable claim payments and eliminates provider friction that creates balance billing problems for plan members.

With a less costly, more compassionate health plan, employers can realize significant savings and reduce fiduciary risks while improving employee health and other benefits.

$2,885 Average Savings Per Employee with NO Cost Shifting | Estimate Your Savings

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