How to Pay Less for Surgery in the USA

Analyze What You've Paid in the Past

Predict What You May Need Going Forward

  • Ask for help. Many benefits consultants will help you analyze past claims data to determine if you have any high-cost surgery exposures that could benefit from a “trim”.  It’s beneficial to find a competent professional without conflicts who will simply analyze your claims data without fear that finding savings means lower kickbacks and trips to Hawaii.  Call for some referrals of independent analysts we know and trust.
  • Expect resistance.  Chances are high that you’ll encounter resistance when you ask for your claims data.  Your TPA or broker will want to know why you want it, what they can help you find, that having claims data risks HIPAA violations, and more. All that is essentially “hogwash”. 
  • Don’t accept excuses. Demand delivery of your requested de-identified data by a certain date. The more resistance you face, the higher the likelihood that there’s concern you’ll find something.  It is not their business why, or who will review the data that they supply.  Ask for data from the last three years. That way, you can spot trends. After all … it’s your data.
  • Make no assumptions. Don’t assume the problem lies only with TPAs, commissions, and double- and triple-dipper kickbacks and trips to exotic destinations. Many times the effect is caused by collusive acts against consumers by hospitals, health systems, physician-hospital networks, and sole supplier medical and surgical groups. 
  • Apples to apples comparisons. You must have total value-based transparency and comparative prices for same procedure bundles along with clinical outcomes to demonstrate high performance at a lower cost.
  • Don’t dismiss savings opportunities on lower-cost/higher-volume procedures.  Some employers with plan participants in a different age range may find savings in reducing the number of ENT (tonsillectomies, sinus surgery, etc.)  general surgery (hernias and gallbladders), gynecology (tubals, endometriosis, and hysterectomies), and urology (obstructed kidney stones, vasectomies, newborns with epispadias, circumcisions, etc.) and sports injuries, fracture care and concussion treatments. Others, with older workforces may find savings in big ticket orthopaedics, neurosurgery, cancer treatments, and cardiovascular procedures.

Use Data From to Pay Less

Without Resorting to "Reference-based" Pricing

Negotiated transparency will always cost less than the amounts you (and your plan participants) may pay with unpredictable reference-based pricing (RBP). 

  • Insufficiency. One reason is that the reference-bases could be wrong. The amount you chose to offer may be way off base and insufficient.  That can happen easily if you acquire data from past claims paid or from data sources like Healthcare Blue Book and Guroo, as their data is based on the old way of purchasing and paying for healthcare, with all the “onion-layers” highlighted in the infographic shown above.
  • Refusal. Another is that many providers will tell you to take your reference-based offer and hit the bricks. This is especially true if someone approaches them with RBP after the procedure as a surprise instead of in advance. 
  • Inequity. If you ask for a provider to accept RBP, without a contract, there’s no incentive for them to agree to the rate or to agree not to balance bill. For one thing, they don’t know if you’ll ever be back to buy more from them. As a one-off, where’s the equity?
Choose a handful of procedures from your previously paid claims analysis. Take note of the amounts you paid and the frequency that you purchased each type of surgical procedure. 

Attend a Workshop with Maria Todd!

August 27, 2019 | St George, UT

Realize hard dollar savings on surgery before October 1 when the deductible satisfied surgery rush begins.

    • Learn how to set up a local or medical travel surgery savings program.
    • Learn how to contract directly with providers, while being mindful of your fiduciary duties under ERISA and IRC213D. 
    • Build in incentives that enhance plan beneficiary satisfaction and drive utilization towards your highest-value providers organically.
    • Put an end to PEPM network access fees! You only need to shortlist a few providers with the surgery bundles you need for your unique plan population.
    • You won’t need to pay someone to negotiate reference-based prices if you have a transparent, value-based contract with great bundled surgery rates.
    • Create your own bespoke national narrow network. It’s easy when you know how and you have all the contract templates in hand, which you’ll receive in class in a bonus package. has arranged a 50% discount with code “CONTAIN19”

for Brokers & Consultants

image of employee benefits committee

We welcome the participation of Brokers and Consultants in utilizing the cost containment strategies of

Your clients look to you for your advice and expertise  to help them discover cost containment solutions to save their health claim dollars.

We invite you to share our service model and bring a value added feature to your clients’ healthplan. Keep in mind that we don’t charge them a network access fee to access our providers.  We work with any size group. Our providers offer their deepest discounts in exchange for easy compliance with their unique programs. In most instances, the bundled case rates are better than rates offered by their ASO, TPA, or other managed care organizations.

For your convenience, we offer additional information and client-facing materials available by request, including power point presentations, brochures, and sample payer contract agreements. Arrange a presentation for your clients with members of our senior team by contacting our Client Concierge Desk at (800) 209 7263 for details. We value your support of

to our Free Group Health Newsletter

We publish a monthly newsletter that features information about new providers, procedures, prices and locations featured on and innovative cost containment solutions to save health claim dollars.
Enter your information, and then please confirm your subscription. If you don’t click the link to confirm, you won’t receive email from us. You are free to unsubscribe anytime you like. 

We keep your data private and share your data only with third parties that make this service possible.

%d bloggers like this: