History
The PforP idea was originally generated by specialty physicians with extensive experience in healthcare policy. While navigating patient care and practice management, they became acutely aware of how complicated healthcare had become, particularly with respect to insurance. Patients could not understand their own policies. Employers had no access to their claim files. Sitting in the middle was an increasingly monolithic insurance industry that consolidated control over the whole process.
Meanwhile, costs continued to rise to unaffordable levels, while patients had to assume a larger portion of those costs. Doctors and hospitals faced decreased payments, forcing them to close shop or merge into ever-expanding, depersonalized health systems.
A simple question needed to be asked: If insurance premiums keep rising, but benefits and payments keep falling, where is all the money going?
“In answer to that question, PforP was created.”
The key, vulnerable sector that PforP identified was the self-insured market, where over three quarters of all commercially-insured lives obtain their health benefits. In this space, it is the employers and unions who assume risk for the health costs of their beneficiaries. Insurance carriers provide only administration services for the self-funded plan, without bearing financial risk.
Alarmingly, the relationship between plan sponsors and their carrier administrators lacks the fundamental transparency typically demanded of most business and financial relationships. Sponsors depend entirely on their carriers for pricing and claims payments. However, carriers are often contractually shielded from disclosing key information required for a plan to ensure that only the required and appropriate amounts due are paid as a result of proper claims adjudication.
Consequently, plan auditors have no means of verifying the accuracy or legitimacy of claims reporting. This lack of transparency exposes self-funded plans to inappropriate charges or misappropriated plan assets.
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Our Team
PforP Health is a collaboration between professionals from across the healthcare sector including population health and regulatory compliance experts, data scientists, healthcare economists, benefit managers, hospital and insurance executives, and multi-specialty physicians, each possessing over 15 years of industry experience.