Use Case / Third-Party Administrators

Cost Containment Intelligence
for Self-Funded Plans

Drive member steerage, repricing accuracy, and network strategy for employer groups. Know which facilities are overcharging, where to build reference-based pricing, and how to defend savings to clients.

The Challenge

Proving Value to Employer Clients

Repricing Accuracy

Your repricing engine uses billed charges × discount percentages. But what if the hospital's chargemaster is inflated 400%? You're leaving money on the table and can't prove it to clients.

Reference-Based Pricing

You want to implement RBP for employer groups, but need market data to set defensible benchmarks. What's a fair rate for an MRI in Cincinnati? Can you defend 150% of Medicare in court?

Provider Steerage

Members are using high-cost facilities for routine procedures. Which providers offer the best value? Where should you steer members for imaging, surgery, PT? Data is scattered across claims and contracts.

The Solution

Market Intelligence for Cost Containment

💰

Actual Negotiated Rate Benchmarks

Stop using chargemaster discounts. See what Anthem, UHC, and BCBS actually pay the same hospitals. Build repricing logic on real market rates, not theoretical discounts. Defend every dollar saved.

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Reference-Based Pricing Support

Access market medians, percentiles, and outlier detection by DRG, CPT, and facility. Set RBP benchmarks you can defend in balance billing disputes. Show courts that 160% of Medicare is reasonable based on market data.

🎯

Provider Steerage Intelligence

Identify cost-effective, high-quality providers for common procedures. Build member steerage programs. "Get your knee MRI at facility X for $450 instead of facility Y at $1,800—same quality, lower cost."

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Client ROI Reporting

Generate employer-facing dashboards showing savings from repricing, steerage, and RBP strategies. Prove your value. Win renewals. Justify your fees with data-driven results.

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Outlier Detection

Flag facilities charging 3x market median. Identify overutilization patterns. Find bundled payment opportunities. Surface cost containment opportunities hiding in claims data.

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Network Strategy for Employer Groups

Design custom networks for large employer clients. Identify tier 1 providers. Model member access. Build narrow networks that reduce spend without sacrificing quality.

Real-World Application

How TPAs Use Healthdex

Case Study: Regional TPA - Reference-Based Pricing Implementation

Scenario: TPA serving 120 employer groups wanted to launch RBP program. Needed market benchmarks to set payment rates and defend balance billing disputes. Internal actuarial team couldn't build defendable rates from claims data alone.
Healthdex Analysis:
  • Pulled negotiated rates for top 50 DRGs and 200 CPT codes across 8-market footprint
  • Calculated market medians and percentile distributions for each procedure
  • Identified that 140% of Medicare aligned with 50th percentile of commercial rates
  • Built RBP payment schedule with market data justification for each code
  • Created balance billing response templates with market comparisons
  • Generated employer-facing ROI projections showing 18-25% savings potential
Result: Launched RBP for 15 employer groups (8,500 lives). First-year savings: $3.2M. Won 92% of balance billing disputes using Healthdex market data. Expanded to 40 groups in year 2. CFO: "We couldn't have defended this program without real market benchmarks."

Case Study: National TPA - Imaging Steerage Program

Scenario: Large TPA identified imaging as top cost driver. Members were using hospital outpatient departments (HOPDs) for routine MRIs at 3-4x the cost of independent imaging centers. Needed data to build steerage program and member communication.
Healthdex Analysis:
  • Pulled rates for CPT 70553 (brain MRI) across all facilities in 25 markets
  • Found HOPD average: $2,240 vs. independent center average: $625
  • Identified 47 high-quality independent centers with rates under $700
  • Mapped member population to nearest low-cost facility (drive-time analysis)
  • Generated member-facing comparison tool: "Your MRI will cost $150 copay at Center A vs. $450 at Hospital B"
  • Modeled savings potential: $1.4M annually if 40% of imaging shifted to preferred facilities
Result: Launched imaging steerage program with member incentives (lower copays at preferred facilities). 52% adoption rate. First-year savings: $1.8M (exceeded projection). Expanded program to PT, lab, and ambulatory surgery. Now using Healthdex for all steerage initiatives.
By The Numbers

Impact for TPA Clients

$1.8M Avg Annual Savings Per Client
18-25% RBP Savings vs. PPO
92% Balance Billing Dispute Win Rate
3 hours To Build Employer ROI Report
Platform Capabilities

Built for Cost Containment Teams

Multi-Market Rate Data

Access negotiated rates across 50+ markets. Filter by payer, facility, procedure. Export benchmarks for repricing engines. API integration available.

RBP Benchmark Tools

Market medians, percentile rankings, outlier detection. Medicare multiplier analysis. Defensible payment schedules. Balance billing response templates.

Provider Cost/Quality Rankings

Identify best-value providers for steerage programs. Overlay CMS quality scores. Build tiered networks. Generate member-facing comparison tools.

Savings Projection Models

Model RBP scenarios. Project steerage program savings. Build employer ROI presentations. Win new business with data-driven proposals.

White-Label Client Reporting

Generate employer dashboards with your branding. Monthly savings reports. Quarterly business reviews. Custom analytics for renewal presentations.

API Access (Enterprise)

Integrate directly into your repricing platform. Automate rate lookups. Build custom cost containment dashboards. Real-time market data feeds.

Ready to Prove ROI to Employer Clients?

Join our 90-day design partner pilot. Access real market rates. Build your RBP program. Generate employer-facing savings reports in minutes instead of days.

Request Pilot Access

Or schedule a 15-minute demo: demo@healthdex.com