Patient Advocacy Playbook for Self-Funded Employers
- finHealth Media
- Jul 8, 2025
- 2 min read
1. Reclaim Oversight of Plan Design
Audit every component of your plan (TPA, PBM, network contracts).
Align incentives to reward value, not volume.
Avoid opaque vendor contracts and insist on full data access.
2. Use Medicare as a Benchmark
Medicare is a defensible, government-audited price reference.
Cap hospital prices (e.g., 150%-200% of Medicare) to avoid uncontrolled billing.
Require transparent billing that references benchmark rates.
3. Support Smart Navigation
Provide access to independent second opinions, centers of excellence, and nurse navigation.
Offer rewards or waived deductibles for choosing high-value providers.
4. Ban Surprise Billing Tactics
Outlaw balance billing in your plan—even if federal law is unclear.
Prohibit providers from charging for services they can’t substantiate with itemized, transparent claims.
5. Empower Members with Real-Time Cost Tools
Use digital platforms that show upfront prices, provider ratings, and out-of-pocket costs.
Make it mobile-friendly and easy to access from anywhere.
6. Vet Your PBM Contracts
Avoid spread pricing and rebate retention.
Prefer pass-through PBMs with guaranteed lowest net costs.
Monitor formulary choices to prevent exclusion of cost-effective alternatives.
7. Actively Monitor Claims
Partner with a claims integrity firm (like finHealth) to catch:
Duplicate charges
Upcoding
Billing for services not rendered
Run quarterly reviews and demand refunds where errors are found.
8. Offer Transparent Billing Support
Equip HR teams to fight denied claims, overcharges, or pre-auth rejections.
Offer member support lines where real humans help employees resolve medical billing issues.
9. Reward Outcomes, Not Network Discounts
Partner with providers or DPC models focused on quality, outcomes, and prevention.
Use risk-sharing contracts instead of fee-for-service.
10. Make It Your Mission
Publicly state: "Our health plan exists to protect employees and their families—not to enrich intermediaries."
Make transparency and fairness a company value.
Contact sales@finhealth.com for more information
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