Planned Administrators Inc. (PAI)

Self-funded health plans serve as a solution for employers prioritizing the health of their workforce in a budget-friendly manner. These plans deliver flexibility in choosing benefits services while lowering the expenses for organizations. This is in stark contrast to fully insured health plans, where employers have no control over premium rates or coverage terms and incur costs even during a claim-free year.

Planned Administrators Inc. (PAI), a national third-party administrator (TPA), is an expert in providing employers with self-funded health plans that bring unparalleled benefits. Its tailored health plans are rooted in a distinct “high quality, low cost” model, which ensures employee well-being and promotes savings for employers.

Since its inception more than four decades ago, PAI has been aiding organizations in creating self-funded health plans by leveraging its partnerships with direct primary care providers, provider discount arrangements, coordination of care solutions, and stop-loss insurers. As a TPA, it works on behalf of its clients to bring together the right combination of solutions into a comprehensive benefit plan that focuses on quality care at lower costs.

Equipped with robust employee health benefits planning expertise, a customized and integrated approach to plan design, ease of access to provider networks, and cutting-edge data analytics capabilities, PAI goes above and beyond to make benefits administration easier for everyone.

“Whether offering self-funded groups cost reduction opportunities and options with our plan designs or administering plans for insurance carriers, we make benefits better for our members,” says George Stiles, president and COO.

PAI operates independently while backed by its parent company—a large Blue Cross Blue Shield Association insurance firm. The infrastructure support from the parent company enables it to securely house and run its own claims management systems and data analytics technology in the latter’s state-of-theart data center.

Tailored Approach to Making Benefits Better

The advantages for PAI’s clients are numerous. Apart from customizing coverage per employee needs and company budgets, they gain greater control over plan design, have more influence over premium rates, and benefit from claim-free years by spending less on healthcare for that particular year.

Through its partnerships with stop-loss insurers, PAI ensures employers mitigate any financial risk by capping their liability for medical expenses. This shields them against expensive claims, making employee health planning more manageable and cost-effective.

Various discount options and access to provider networks that give discounted services further reduce costs for clients. One way PAI offers cost optimization is through referencebased pricing, which is a negotiated rate with an insurance provider based on the Medicare fee schedule and reimbursement rates.

The new version of reference-based pricing is brought by PAI through a contracted arrangement with a provider, as opposed to the traditional contract-less arrangements. This ensures the members are not subject to any balance billing, facilitating quality care at the lowest possible cost.

Sharing information with all health plan stakeholders is central to PAI’s endeavors to promote cost savings and quality in healthcare. A portal empowers clients with detailed information about cost drivers and plan spending. They can access reports and run their own analytics, with flexibility in how they interpret and use the data. The company’s specialized teams also provide regular insights into cost drivers for employee health issues.

With PAI, clients have the freedom to opt for the pharmacy solutions of their choice from a range of options. While many TPAs avoid direct integrations with “external” pharmacy benefit managers (PBMs), PAI takes a different approach.

Our model— the result of a strong emphasis on innovation and out-of-thebox thinking— brings excellent outcomes for patients, providers and employers alike

Pharmacy data from every client’s PBM is ingested into PAI’s analytic tool included in the group analytics. It also works with direct primary care providers to receive visit “claim” data for inclusion in the analytics tool, allowing for a complete picture of each member’s medical history. Understanding cost drivers through data analysis allows PAI to implement effective, self-funded health benefits programs.

Customization such as health alerts on cell phones, tailored health coaching, care and disease management and wellness programs for plan members further promote healthy living, further lowering costs.

A Health Plan Model with a Difference

A strong willingness to adopt new approaches defines PAI’s employee benefits management endeavors. This is reflected in its efforts to explore unconventional solutions when designing customized plans, like discount programs, sourcing pharmaceuticals from foreign markets, and leveraging advanced technologies like artificial intelligence.

One example is PAI’s novel health plan that leverages the direct primary care (DPC) model in partnership with Proactive MD, a South Carolina-based advanced primary care group. In this model, an employer pays a monthly fee to the primary care provider, giving its employees unlimited access to services at that care facility. The member-focused model offers quick access to providers, longer consultations during physician visits, and more personalized care.

PAI strongly believes the DPC model can help address healthcare issues in the U.S. by providing a more patientcentric approach. In most cases where a primary care doctor is part of a larger health (hospital) system, the primary care provider refers patients to specialists within their hospital system, not necessarily to the best specialist for that member, potentially driving up costs.PAI brings a shift toward cost-effective care by placing emphasis on primary care and selecting specialists based on individual merit and cost, rather than hospital affiliation.

These partnerships also give the company access to data on patient visits and referrals, the quality of care and the costs involved. The data is leveraged to ensure that referrals outside the primary care clinic are made to high-quality providers who offer good value with lower fees.

One of PAI’s and Proactive MD’s mutual clients, a university in South Carolina, decided that all employees would receive primary care from Proactive MD. Specialist services or hospital admissions will only be covered by the university if approved by Proactive MD’s primary care doctors.

The care coordination is further enhanced by keeping the primary care physician continually informed during a referred patient’s treatment in specialized care or hospitals. This helps the physician in administering better care during annual health checks and follow-ups.

“Our model—the result of a strong emphasis on innovation and out-of-thebox thinking—brings excellent outcomes for patients, providers and employers alike,” says Stiles.

Shaping the Future of Health Benefits Administration

PAI has evolved through the decades in the employee benefits arena. Since inception, its work on self-funded plans has been largely concentrated in South Carolina, with some clients in the neighboring states of North Carolina and Florida. The company eventually added insurance carrier administration to its back-office processing operations, which has been a significant focus area in the last two decades.

Propelling the company forward is a team of benefits planning experts, enabling it to continually deliver on its mission statement of making benefits better. The majority of its senior leadership team, comprising seasoned industry leaders and veterans, has been associated with PAI for decades and is deeply passionate about taking employee health benefits administration to new heights.

Today, PAI is setting the pace in the market with its self-funded plan administration capabilities. Its growth is largely propelled by its partnership with Proactive MD and a surge in market demand for reference-based pricing. This allows it to customize benefit plans based on the needs of employers in specific markets and rapidly anticipate trends in existing and newer markets.

These developments have opened doors for PAI to expand its selffunded health plan administration at a national level and strengthen its drive to be positioned at the forefront of the industry. It seeks to introduce more services with a focus on gaining better control over benefits management internally, foregoing dependency on vendor partners.

Driven by the goal to maximize the potential of self-funded health plans and an ability to deliver unmatched benefits administration, PAI is a reliable ally to employers and insurers alike—with the employee as the ultimate beneficiary.