March 25, 2020

Questions you might not be asking your self-funded health plan administrator – but should be.

Part 1: Key questions your organization should consider asking from a health plan provider

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Evaluating your self-funded health plan: Part 1

As healthcare costs continue to rise every year, many employers worry they aren’t getting what they pay for. In 2019, U.S. private employers paid 20% of all healthcare costs, totaling approximately $1.3 trillion1. It’s no wonder that questions about healthcare plan investments are keeping finance executives and HR leaders up at night.

It’s critical for employers to continually evaluate their self-funded healthcare plan to ensure it protects and improves the health of employees while providing costs savings for the company. If your company feels like it’s time to evaluate an alternative health plan provider, there are some key questions you’ll want to consider asking.

In part one of this two part series, we’ve outlined key questions your organization should consider asking from a health plan provider in regards to their organizational structure and IT Team’s capabilities, along with details on each question’s importance.

Organizational Structure:

Q1: What is the ownership structure of the organization?

Why it’s important to know: You want to ensure there are no conflicts of interest of how the structure of the organization is built/operated.

Q2: How long has your organization operated under its current ownership structure?

Why it’s important to know: It’s important to seek an established organization that has a track record of success under its current organizational structure and leadership team. For example, mergers and acquisitions may distract the company from its primary role of supervising health plans. Also, organizational changes may cause employee turnover and shifts in operational efficiencies that may not be beneficial for clients.

Q3: What systems and personnel/departments are outsourced?

Why it’s important to know:  When certain systems, personnel or departments are outsourced and out of the main vendor’s control, that may impact how smoothly operations run and influence the end user’s experience (your employees). The more companies involved in the process, more fragmentation may exist leaving vulnerabilities for error and duplications.

Q4: Please describe where the following departments or functions are located and/or outsourced to:

  • Clinical (case management, nurses, health coaches)
  • Customer Service
  • IT
  • Account Management
  • Sales Team
  • Eligibility
  • Claims Auditors and Examiners
  • Reinsurance
  • Claims Appeals
  • Subrogation
  • Compliance/Legal

Why it’s important to know:  By identifying which departments or functions are outsourced, your company will be able to gain insight into how its health plan would be managed interdepartmentally and across other vendors. This will also give you an understanding of how those vendors work together and the type of experience your employees would receive if you chose to work with the provider.

Q5:  Where is your IT team located and what is your IT structure?

Why it’s important to know: It’s important to know if the provider’s IT team, as well as technology platforms are internal or outsourced – as that affects how system maintenance and updates are handled on a regular basis. An internal IT team may be able to address and resolve issues or new requests quicker than an outsourced team that handles multiple vendor requests. A solid IT infrastructure and technology platform control are especially crucial in unforeseen situations, like the COVID-19 pandemic, that require nimble business continuity response.

Q6: Please list any systems, portals, reporting or analytics that have been developed by your IT team and that are proprietary to your organization.

Why it’s important to know: Operational systems, portals and reporting/analytics are essential for today’s self-funded healthcare plan. Transparency into these systems and your data accessibility is key. Be sure to dig into the systems, portals and overall structure to understand how everything works together. Multiple systems and vendors can potentially create a fragmented experience for customers and plan members – this is why it’s crucial to dive below surface level to better understand your health plan partner’s infrastructure.

Preparing questions and asking for details:

Preparing questions to ask your self-funded health plan partner may seem like a daunting process, but it’s important to be as detailed as possible in order to gain a thorough look into how the healthcare provider’s organization is structured and what functions may be outsourced.

Stay tuned for the second part of this series where we review the important questions you’ll want to ask your health plan partner about Claims and Case Management support and processes.

Read Part 2 of this article series.



1). Kaiser Family Fund 2019 Employer Health Benefits Survey. Published: September 25, 2019. Retrieved from: