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3 Kinds of Broker/EBC Rent-Seeking Payment Models - A Lawyer's Perspective, With Doug Aldeen. EP512

Relentless Health Value · 2026-05-27 · 37 min

0:00--:--

Key moments - from our scoring

Substance score

70 / 100

Five dimensions, 20 points each

Insight Density15 / 20
Originality12 / 20
Guest Caliber14 / 20
Specificity & Evidence16 / 20
Conversational Craft13 / 20

This episode addresses a critical pain point for self-insured plan sponsors: the hidden ways brokers and EBCs extract value through compensation arrangements that don't serve plan interests. Doug Aldeen, an experienced healthcare attorney, dissects three distinct problematic models. First, direct compensation agreements often lack transparency - plans frequently overpay without understanding the formula, sometimes by millions compared to market rates. Second, brokers recommend rent-seeking solutions where they profit from perverse incentives: reference-based pricing vendors charging percentage-of-savings fees (incentivizing higher hospital prices), balance billing programs that charge $2.2 million to defend against $94,000 in claims in jurisdictions where balance billing is illegal, and voluntary benefits with 70-90% front-loaded commissions. Third, vendors pay brokers undisclosed "marketing fees" or other service payments at the book-of-business level - legal under the Consolidated Appropriations Act's ambiguous language but fundamentally misaligned. Aldeen offers a practical six-step roadmap: ask "why" five times to validate necessity, calculate true ROI, and consider downstream consequences. Real examples include the Ohio Potato Company paying $2.9 million in broker fees that depleted medical claims. The episode is essential for CFOs, benefits directors, and plan sponsors evaluating broker relationships and considering RFP processes.

Key takeaways

  • →Direct broker compensation often lacks transparency, with similar-sized groups paying wildly different amounts for identical services due to complex formulas plan sponsors don't fully understand.
  • →Brokers recommending reference-based pricing with percentage-of-savings fee models or balance billing programs create perverse incentives - they profit more when hospital prices rise or when plans pay for unnecessary services.
  • →Vendors legally pay brokers undisclosed "marketing fees" or service payments at the book-of-business level under CAA loopholes, creating hidden conflicts where brokers recommend solutions that benefit the broker, not the plan.
  • →The Ohio Potato Company example shows how level-funded arrangements can fail catastrophically when brokers prioritize fees over plan sustainability, forcing companies into expensive fully-insured alternatives.
  • →Ask "why" five times and calculate ROI before implementing any broker recommendation - many plans overpay for services they don't legally need or that generate vendor revenue exceeding claimed savings.

Guests

Doug Aldeen

Topics in this episode

Level-funded health plansReference-based pricing (RBP)Percentage-of-savings fee modelsBalance billing defense vendorsConsolidated Appropriations Act (CAA)Point solutions and PBMsVoluntary benefits commissionsTexas District Hospital statuteCost-of-savings modelsSelf-insured plans

Questions this episode answers

What are the three main ways brokers and EBCs make money in ways that hurt plan sponsors?

Direct compensation agreements that lack transparency, rent-seeking solution recommendations where brokers profit from perverse incentives (like percentage-of-savings pricing on reference-based pricing), and undisclosed vendor payments where brokers receive fees from point solutions supposedly recommended for plan benefit.

Why would a broker recommend a balance billing vendor to a plan in Texas?

Because it generates revenue for the broker even though Texas District Hospital statute prohibits balance billing - one plan paid $2.2 million in fees over three years to defend against just $94,000 in claims that would have been protected anyway by law.

What does the Consolidated Appropriations Act (CAA) have to do with undisclosed broker payments?

The CAA has ambiguous language on disclosure requirements, allowing vendors to pay brokers for "marketing services" or "services to the vendor" at the book-of-business level without disclosing these payments to individual plans, even when they create conflicts of interest.

How can a reference-based pricing vendor create perverse incentives for brokers?

If the RBP vendor charges a percentage of savings (like 20% of repriced amounts), the broker who placed them profits more as hospital prices rise - so both the broker and vendor benefit from higher baseline prices rather than lower costs for the plan.

What should a plan sponsor do to audit whether their broker is conflicted?

Ask "why" five times about each recommendation, calculate the true ROI (fees paid versus savings realized), and consider downstream consequences if a solution fails - like being forced into expensive fully-insured coverage if a level-funding arrangement collapses.

What our scoring noted

Our reviewer’s read on each dimension, with quotes from the episode.

Insight Density

15 / 20

The episode contains substantial, actionable insights about broker compensation models and rent-seeking behavior, including specific examples (Ohio Potato Company, balance billing programs, reference-based pricing fee structures). However, the content is somewhat padded with introductory framing, repetitive messaging, and promotional segments that dilute the insight-per-minute ratio. A focused B2B operator would extract valuable material on hidden fee structures and conflict-of-interest scenarios.

There's three layers. There's both the direct compensation, more importantly, there's the indirect compensation, but then even on a third level is do you even need whatever product they're peddling?
the broker was paid over $2 million in a level funded arrangement. It completely depleted the claims fund.

Originality

12 / 20

While the episode tackles real problems (undisclosed vendor relationships, percentage-of-savings models creating perverse incentives), these issues have been covered in prior healthcare media and by other commentators mentioned in the episode itself (Donovan Pyle, Chris Deacon, Justin Leader). The framing around the 'three kinds' model provides some structure, but the core insights - that brokers have conflicts of interest and hidden payments exist - are not novel. The conversation is competent but largely recycles established critiques.

Brokers slash EBCs recommending rent seeking solutions to their clients. Like a broker or EBC suggests a solution to their clients where the solution itself makes money on a perverse incentive
Chris Deacon and Justin Leader also wrote posts about this. Donovan Pyle wrote a whole book about it.

Guest Caliber

14 / 20

Doug Aldeen is a practicing attorney with real litigation experience in self-insured plans and broker disputes, giving him credibility to discuss legal outcomes and contract structures. However, the transcript provides minimal detail about his specific background, current role, client base, or notable cases he has personally handled. He appears knowledgeable but is introduced primarily by title rather than demonstrated track record, limiting the clarity of his caliber.

Doug Aldeen, who is a well-known attorney who has spent many years in the self-insured space.
I've been seeing this more frequently. More frequently.

Specificity & Evidence

16 / 20

The episode excels at naming specific examples with dollar figures: Ohio Potato Company ($1.9M year one, $800K year two, $600K deficit); balance billing case ($2.2M in fees for $94K in actual risk); voluntary benefits commissions (70-90% year one); reference-based pricing markup example ($10K CT scan, $9K savings at 20% fee = $1,800 vendor payment). The 17,000% markup claim is striking. However, some claims lack full attribution or verification (e.g., 'someone with purview over 200 plans'), and there's occasional vagueness on timelines and contract terms.

the broker was paid over $2 million in a level funded arrangement
the broker or this vendor took $1.9 million for year one. They took $800,000 for year two. And then the company that they were advising, they found out that they were $600,000 in deficit.

Conversational Craft

13 / 20

Host Stacey Richter demonstrates solid follow-up with questions like 'Explain what cost of savings means' and 'Give me another rent seeking solution recommendation,' which push Aldeen into concrete examples. However, there are missed opportunities to press harder: Aldeen makes claims like 'I've been seeing this more frequently' without being asked for specifics on prevalence or enforcement risk; the guest's somewhat evasive language on certain points ('could be,' 'I dunno if') isn't challenged; and Richter often retreats into validation or frame-setting rather than probing disagreement or asking for counterarguments.

Explain what cost of savings means.
Do you see this a lot?

Conversation analysis

Computed from the transcript - who did the talking, and the words that came up most.

Most-used words

broker58plan53vendor25paid24doug22seeking15paying15balance14hospital14rent13solution13point13brokers12value11slash11listen11

Episode notes

A Lawyer's Field Guide to Rent-Seeking Broker and EBC Payment Models. Epsiode 512. Brokers and employee benefit consultants often get compensated in ways health plans never fully see - and even when the dollars are technically disclosed, the math can hide an enormous overcharge. In this episode, Stacey Richter speaks with Doug Aldeen, JD, an ERISA healthcare attorney who has spent decades in the self-funded space, about the legal danger zones where broker and EBC payment models go wrong: rent-seeking solution recommendations, undisclosed vendor payments, and front-loaded voluntary-benefits commissions - and the practical roadmap any plan sponsor can use to catch them before they cost millions.

Full transcript

37 min

Transcribed and scored by The B2B Podcast Index.

This file was generated by Descript Episode 512. Three Kinds of Broker/EBC Rent Seeking Payment Models. A Lawyer's Perspective. Today I am speaking with Doug Aldeen.

American Healthcare Entrepreneurs and Executives You Want to Know, Talking. Relentlessly Seeking Value. I wanted to talk to a lawyer because yeah, lawyers are the ones that see stuff that falls the whole way down to the level of legal action. But I wanted to find out what are the main categories of things that wind up in legal land when it comes to broker or EBC, employee benefit consultant payment agreements?

Like what are the top ways that compensation agreements go horribly awry? Doug Aldeen, my guest today rose to the challenge, and let me just state for the record that while there are a whole lot of brokers and EBCs who would or do engage in some of these practices, there are also many who do not and or it might not be the broker slash EBC themselves, but the company that they work for who is up to some of the things that we're gonna be talking about in the episode today. But I really for sure want to support the gang of honest actors, great fee-based, integrity based brokers and EBCs, and I wanna support them all day long, many of whom listen to the show and are part of the Relentless Health Value Tribe.

But let's talk about how the rent seeking ones roll so that you can spot them. See what they did there. So yeah, the first kind of ground zero that Doug and I talk about today is just upfront direct compensation agreements, which may be just ridiculously complicated and or ridiculously expensive compared to what others are charging for a similar group. Where there's mystery, there is margin that is so relevant in so many situations, and this is just another one of them.

So then after that, Doug and I move on and we get into three categories of stuff that sits in that undisclosed or maybe even disclosed zone, where just the whole model of payments is problematic on its face. First up, and this is a biggie. Brokers slash EBCs recommending rent seeking solutions to their clients. Like a broker or EBC suggests a solution to their clients where the solution itself makes money on a perverse incentive, and then the broker or EBC gets a piece of that action, which might be called shared savings.

So yeah, even if the dollars to the broker or EBC are disclosed, a naive plan administrator might not see that overcharged for what it really is, and Doug gives a bunch of examples in the show that follows. Chris Deacon and Justin Leader also wrote posts about this. Donovan Pyle wrote a whole book about it. I will put links in the show notes.

Hi, this is Mark Cuban of costplusdrugs.com, and not only do I listen to every episode of Relentless Healthcare Value, but it is the most incredible, stupendous amazing healthcare podcast in the history of all healthcare podcasts. So make sure to listen every single time. Okay, the next big category of typical payment model methodologies that Doug Aldeen, again a lawyer, has seen plans get themselves into trouble with their EBCs and brokers, the ones who are sharks.

I mean, circling the plan like it's a gold mine. This big category is undisclosed payments from vendors who the plan doesn't realize has a business relationship with the EBC or broker. This can also be a whole basket of solutions that the EBC slash broker wants to install, which is basically this problematic payment model at scale and right, this matters because then the plan doesn't know if this particular point solution, PBM, stop-loss carrier, right, they think their broker EBC is recommending it because it's the best option for that particular plan, not understanding that it's the right option for the broker or EBC.

And these dollars can be undisclosed because to a certain extent, the Consolidated Appropriations Act, it's a little bit unclear on certain points. There's some loopholes if you go looking for them because you are so inclined. We get into more detail on this later on after this. Doug offers a really great roadmap with six steps in it for any plan to really think about as they consider, first, the maybe integrity of their broker or EBC and what is being recommended to the plan.

And that's important because look, and we say this in the conversation that falls, but I'm gonna say it again here loudly. If a plan realizes that their broker or EBC is not really serving the best interest of the plan, there are great options out there. There are great EBCs and brokers who are honest, upstanding, that really care about their clients, their plans, their members, and doing the right thing. But telling the difference between the not so good ones and the good ones, takes some diligence, takes some validation on the part of the plan sponsor.

It just does. But the amount of dollars that can be saved is millions, and this is actually saving those millions is actually better for the plan because it's not like those do, they were going in somebody's pocket. It's not like they were being put towards better, safer, lower premiums. These are dollars that can be cut and the plan is actually better.

My guest today, as I have mentioned at least several times already, is Doug Aldean, who is a well-known attorney who has spent many years in the self-insured space. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group, and I do want to give a shout out and a thanks to our 2026 series underwriter Payerset. Thank you so much for your financial support.

That helps keep this podcast on the air. And with that, here is my conversation with Doug Aldeen. Doug Aldeen, welcome to Relentless Health Value. Actually, good to be here.

Happy to, happy to be chatting with you. It's nice to have you back. So let's just take this from the why. Why is reviewing broker slash employee benefit consultant compensation extremely important to look into?

Like are we talking change in the couch cushions here and this is just, the juice ain't worth the squeeze. I think there's three layers. There's both the direct compensation, more importantly, there's the indirect compensation, but then even on a third level is do you even need whatever product they're peddling? And so I, I think that there's three layers you go through.

What's the direct amount that's above board everybody sees, pays, acknowledges the indirect stuff can get super murky. When you look at how those arrangements are structured. And then thirdly, is it a service and or product that's even appropriate for the group follow the money? I mean, how much is the broker getting paid to place something like that?

With the group? I mean, 'cause a group I can guarantee you has no clue. Like if you look across different groups, just even how much the direct fees getting paid are. If there's one group who has been with one consultant or broker for a really long time, the only frame of reference they have is that one EBC or broker.

And they haven't done an RFP or they haven't shopped around they may not even realize just how wildly overpriced the direct comp that's even being reported is. Oh yeah. Do you even understand what the formula is on the direct compensation? Because it should not take a NASA scientist to reverse engineer.

What do we have? What are we paying here? So. Lot of different levels.

There was just the, the Ohio Potato company, did you wanna talk about that? Yeah. So the broker was paid over $2 million in a level funded arrangement. It completely depleted the claims fund.

I mean, the broker was paid handsomely, but when it came time to pay the medical, I mean, so who's losing? I mean, the patients are losing, the doctors are losing. The facility is losing. Only people who are winning are is the broker who took the fee.

Yeah. So the broker or this vendor took $1.9 million for year one. They took $800,000 for year two.

And then the company that they were advising, they found out that they were $600,000 in deficit. And balance billing going crazy. I mean, people just getting shelled. Unbelievably awful.

It's a gift that keeps on giving because now the group's gonna have to probably go to a fully insured arrangement. You know, they're gonna overpay for that. So there's a downstream effect as well. I was talking to someone who would know the other day.

He has purview over how much hundreds of plans are paying their brokers or EBCs employee benefit consultants. And for similar sized groups with similar sized needs, even just looking at the direct compensation, he was telling me that the variation is big. Some groups are paying wildly higher, even just direct compensation than other groups for the exact same services. So yeah, don't overlook this one.

And I'd also call it kind of our ground zero way. Plans, wind up paying some amount to their broker slash EBC and just be fuzzy on how they got to that dollar figure. You can see how this can happen if, like Doug just said, it takes a NASA engineer to understand the basic compensation agreement. So with this baseline, let's move on to what I wanted to get to with Doug and what the title of this show suggests, from his standpoint as an attorney getting pulled into stuff that you'd pull an attorney into, where does he see the biggest problems with plans not really understanding how the payment model itself is kind of nefarious.

So here we go. Let's get into our first category where brokers are making money undisclosed slash disclosed, but just in ways that the plan may not be quite aware of or aware of what the math adds up, to your point. The first way brokers slash EBCs may be getting compensated where there's more than meets the eye might be rent seeking solution recommendations. Do you wanna talk about this?

This is an example, so you could be in a reference based pricing program. And the vendor is using a cost of savings models. That's a really interesting example because a lot of folks are immediately gonna think to themselves, well, reference-based pricing is actually a way to save money on these underlying hospital charges. You could have implemented a reference-based pricing program, which is tied to a cost of savings.

So as the hospital prices increase, and they are increasing geometrically, by the way, the reference-based pricing vendor is going to receive a fee and it's going to increase as those hospital charges increase. But then the, the broker's fee, who placed the reference-based pricing vendor with the group, presumably his fees are going to increase as well, as long as that relationship exists. Explain what cost of savings means. So if a hospital charges $10,000 for a CT scan and you, there's a 20% cost of savings fee in order, if you reduce it, frankly, it, it's pretty easy to do.

So you just say it's a thousand dollars. You reprice the CT scan too, which is fair. There's a $9,000 savings at 20%, so the RBR vendor is gonna get 1800. So 9,000 times 20% is 1800.

So you're already getting paid more than the facility. And then the broker's fee, however it's calculated on the backside, is going get getting paid something as well. You know, and I dunno if it's a 50/50 split or whatever it may be, but I mean, it's gonna be pretty close to what the hospital's getting paid, if not more. Listen to the show with Cynthia Fisher that talks about that same idea in a out of network version.

It's kind of like, you know, same trick, different day. The incentive here is to have those hospital prices get higher or higher, or if the members go to the highest price place in a way, I mean, there's just some weird incentives that wind up happening here. You can go into any number of facilities and look at the services that people actually use. And the markup could be 17000%.

So not all the diagnostics, the CT, MRI, anesthesiology, 17000% of a markup. So I mean, you can think about the fees that are being generated on the backside when those claims get repriced. If the broker places a plan with an RBP, reference-based pricing vendor that charges in this way, a percentage of the savings. If you start connecting the dots, then you've got an EBC or a broker who knows exactly what they're doing.

They know exactly how much they're gonna get paid by using this RBP vendor, which is charging their client in this particular way. They know exactly about the 17000% markups and you hear this stuff all the time. So in this particular way, you wind up with a broker who can make a lot, a lot of money by advising their client base to work with this particular, and there's plenty of RBP vendors who do not operate in this, in this model, but if anyone does like this is what downstream is gonna happen.

Absolutely correct. Give me another rent seeking solution recommendations. A balance billing program is, so just, just by way of background, I mean. Most balanced billing programs are gonna have a base level of reimbursement, let's just call it 150% of Medicare.

What Doug is talking about here is, if a plan puts in, for example, an RBP, reference-based pricing program and pays a hospital some calculated amount, the hospital may disagree with that amount. And they may go after the patient in this case for the balance of what the hospital thinks it is still owed after that payment. There are companies you can hire to take the risk for possible balance billing, and Doug explains the rent seeking way to go about that service. I'd also keep in mind that there are some areas of the country where a hospital is not even allowed to balance bill, such as in Texas with the Texas District Hospital statute.

So definitely from the plan perspective, this falls into the bucket of what Doug was talking about earlier, things that you don't really need. In order to qualify for balance bill defense, I mean, you're gonna have a risk corridor that the plan is gonna have to bear the responsibility of payments. So typically that's between 150% of Medicare and 200% of Medicare, where the plan would end up having to pay whatever you know the bill is. But in the event that it's 201% and above, the balance billing vendor would then have that risk.

As an example, you had one where not only was this group, a majority of the claims going through a Texas District Hospital statute where there is no balance billing authority. Okay? So nobody's gonna be getting balance, but at least they don't have the authority to do it. But then to qualify for a balanced bill, and you look at the PEPM that was being paid, this was 2.

2 million over three plan years relative to a captive payout of $94,320. There was a balance bill vendor in the mix here, and they took $2.2 million in fees. That's how much the plan paid them, $2.

2 million in fees, and the whole time, what was in question was $94,000. Correct. So this particular plan paid $2.2 million of its own plan members and the employer's money to have at $94,000.

A service that wasn't even appropriate or needed. As the icing on the cake because with these balance bills statutes, the plan would've had that 94k anyway, like so it was completely irrelevant. Irrelevant. That's probably the very definition of a rent seeking vendor placement by this broker.

So you, you really need to do, you know, a traditional ROI or cost benefit analysis. Is it even appropriate? If a hospital can't balance bill, why would you even have the service? Okay, as an example.

But more importantly, does that solution what you're paying? Is it more than what you're, you're getting in benefits in terms of the savings or the impact to the plan, which in many cases happens more frequently than people think. And then the third kind of example of maybe rent seeking is these voluntary benefits, which I know you have talked a lot about. I mean the, a lot of these voluntary benefits are not worth the paper that they're written on.

And the commission structure typically is front loaded in that first year. Because these, these are all employee paid commissions. I had been talking to someone with a large purview over about 200 self-insured plans financials. And he said exactly the same thing.

He pointed out that across those 200 plans, just the amount of money that was being made off of the voluntary benefits and just how obvious it was if you really start looking into it, how the carriers that were being offered for these voluntary benefits, when the carriers wound up changing, you know, the plans that were being offered by the brokers. He said it was just stunningly obvious how the whole operation was constructed to maximize the EBC or brokers commission payouts.

That's exactly right. In the commissions, you know, anywhere from 70 to 90% on that first year and no claims you're getting paid. It literally is a pass through to the broker in terms of the commission. That's it.

Okay, so now we move on into the category of undisclosed payments, just flat out undisclosed stuff. And this could be pernicious if the plan thinks that their broker EBC has selected whatever vendor for reasons such as this is the best vendor for the plan. It's the best price, it's the highest value, whatever. Not realizing that this vendor was actually selected because this is the best vendor for the broker slash EBC or their agency.

And that is a really, really key point. Sometimes the broker slash EBC has no kind of idea how much their agency, their company is making off of the relationship with some vendor. This individual is just told that this is the preferred partner. I'm gonna ask you to give me some examples, but it is my understanding, and I'm also gonna ask you to correct me if I'm wrong here.

It is allowed to be undisclosed because it's done at the book of business level. There's some vendor that is paying the broker for services for the vendor. So now it's not, they're not paying for anything to do with your plan in particular, like this vendor has a separate business relationship with the broker and they're paying the broker to do something that has nothing to do with the plan. So you could take any number of different point solutions, whatever that may be, and the broker is not paid by the plan, but rather the broker is paid by the point solution on their side of the ledger.

Let's just say it's a cost of savings model, whatever it may be. So the plan pays the point solution, but then the point solution is gonna pay out of their fee, the broker. And that doesn't have to be disclosed. Yeah.

And it doesn't have to be disclosed because it's tagged as like providing services to the vendor, like they're providing marketing services or something that is to the vendor itself. So the vendor is paying them for services rendered. You can sort of see why, well, logically, I mean, why would I report that to the plan? But at the same time, if I know, if I'm a broker and I know that this one guy, this one diabetes solution, I'm gonna get paid for my marketing services.

Then I have a very big vested interest to pick diabetes point solution one, and that rationale may have nothing to do with what their quantified patient reported outcomes are, or savings to the plan downstream or anything like that. Well said. Do you see this a lot? Believe it or not, I've been seeing this more frequently.

More frequently. More frequently, just well, because you think about, I mean the CAA is a pretty well-known vehicle out there right now in the marketplace. The Consolidated Appropriations Act, you mean? Exactly.

And so the disclosures in terms of, you know, who's being paid what. Point solution A, have any, you know, reason to provide that he's paying Doug or Stacey on their side of the ledger? No, none. The point being made here, it's probably a few fold, and I didn't double check this with Doug, but realized in the re-listen that it's a bit of a hanging chad.

What I hear often enough with the CAA, the Consolidated Appropriations Act, is that it is potentially unclear on a few key points, which could be exploited if one is so inclined, and also enforcement of the CAA. Spotty at best. So if a broker slash EBC and or their company is hellbent to maximize their revenue, their income at the expense of their clients, first off, what are the odds of a CAA violation even being discovered in the first place? Because let's get real, most planned administrators do not listen to the show.

Or they fall victim to the various things discussed in that show with Lee Lewis from several weeks ago, and they turn a blind eye. Or they do notice the plan and they're pissed about it, but like what do you do now? Do you sue? Do you call the DOJ or the DOL?

What are the chances that whatever actions that plan decides to take are going to amount to consequences substantial enough for any broker brokerage, consultancy company making lots of money to reevaluate and rethink their ways. So point solutions for sure, and I hear this a lot with PBMs as well, listen to the show with AJ Loiacono from a couple of years ago, where if a PBM wants to even participate in an RFP, you've got a broker on the other side who's just like, well, you know, it's 50 grand just to get in.

It's 50 grand just to be on the sheet. Rent seeking at its best. Yeah. I'm kind of thinking we made rent seeking that second category, but the more I'm thinking about this, the more I'm just like that is the valence that sits over pretty much all of this.

Right? Because also with PBMs, every single time, any plans, members goes into that pharmacy and gets a script filled. I mean, you see often enough contracts where some big brokerage house is getting paid by the PBM $7 a script, $2.50 a script.

They often don't call it a payment, they call it a discount, or they call it something else. There's one contract I looked at, which specifically said, well, we're gonna call this a discount. So it is not subject to disclosure, right? Like so.

It's so bold, it's so boldly done. It is. Caveat emptor Caveat emptor. Buyer beware.

Let's talk about actionable advice for plan sponsors now. The first bit of advice that you had given before, which I think is really sage, is ask why five times? Why is this being recommended? Do you wanna just kind of go through an example of asking why five times where you wind up?

Do you even need, or is it an appropriate service? Why do we need this? And an example we can just use is, is the balance billing. So if the local hospital doesn't have authority to balance bill pursuant to its FAP or by statute in Texas, why do you need it?

You don't. Why do I need it? Why is this particular vendor being recommended? Like, why this one over that one?

Why is it being done this way? Like, why is the payment model this way? Just really think through what each of these recommendations are and just do the why, why I thing? Second, what's the ROI?

So let's just say for example, it is appropriate, what's the ROI? What am I paying to generate this type of savings? In other words, are you gonna be paid? Is a vendor or the point solution gonna be getting paid more than what I'm realizing in terms of the benefit.

Right? Like it could be a relatively small problem that we wind up paying lots and lots of money to solve. And yeah. And then I would say thirdly, in the event it goes south and let's just use a level funding issue with the Oregon Potato Company, what's the downstream impact in terms of finding another arrangement?

So in other words, not only did you lose $2.1 million, but now you're gonna have to belly up to a fully insured arrangement, and you're gonna have to pay through the nose for the privilege. In other words, if the level funding plan fails, and the same broker knows that if the level funding fails, they're gonna get your fully insured business and they actually make more on the fully insured business, then they're, they could be thinking to themselves, sure, try whatever the heck you want.

Right? Because now I'm gonna get you coming and going. Which brings us to the, so we just talked about the first thing in the roadmap, which is ask a lot of why's. The second item in our roadmap here is demystifying the commission structure.

And you alluded to this earlier, would, we kind of were talking about this and you said like you need a degree in higher math to figure out what that commission structure is. Like that in and of itself, is a tell. So if you actually look at the language under the Consolidated Appropriations Act, I mean it specifically says, you know, allows the plan sponsor to reasonably conclude what that fee is. Well, I mean, little bit gray, but I mean, it shouldn't require a NASA scientist to reverse engineer the compensation formula.

I mean, two sentences max. I'm getting paid X. Thank you. I mean.

I don't know what else really needs to be said. And I think that this one is pretty simple, but really powerful, Doug. The more complicated the commission structure is to explain like if there's four pages or 60 pages in, the plan documents in the contract, it takes that long to explain what the commission structure is. Yes, it is.

So second item on our roadmap is demystify the commission structure or think about what that commission structure is and how long it takes to talk about. And as you said, there is a requirement in the Consolidated Appropriations Act that says, Plan must reasonably be able to figure out what that commission structure is. We should not have to go to MIT to hire somebody to figure out what I'm getting paid or what I'm paying the broker. Third piece of advice along these lines, I mean obviously all of these are sort of a build and interlock, but use a broker, RFP from a third party reputable source.

There's a bunch of open source examples that are available in the market right now. We had Dave Chase on talking about Nautilus Health has some of these 32BJ, they had a PBM, they may have a broker one as well. Or working with a very, and and again, be real careful if there is an entity that you're choosing to work with. There's really good ones out there.

Yeah, I mean, you definitely have to have an independent RFP that's gonna give you the answers you need to formulate whatever position you're gonna take. Right. But there's plenty who. Their business is doing RFPs and they're making money doing it in ways that are undisclosed.

Fourth thing on our roadmap, Doug, audit your data and your documents. What do you mean by that? Auditing claims. I mean, so when you think about, not only do you need to look at all the different arrangements between, for example, like the stop loss in your plan document.

Nine times out of 10 there's gonna be a different level of reimbursement. So the plan's gonna pay X. Your stop-loss is gonna reimburse Y. So there's gonna be a gap between what the plan pays and what they're gonna get reimbursed.

And then when you start looking at who's placing the stop-loss carrier, typically a TPA. But you know, the broker has an involvement in that, but you really have to understand what that ecosystem is, why it's set up that way. And then was getting paid what, based on those arrangements that are with the plan. Yeah.

It's amazing. It took this long for stop-loss coverage to come up in this conversation. Wow, it's so important. I mean, usually paying for stop loss is the biggest, if not one of the biggest expenses for any given plan.

Listen to the way there's a two part show with Andreas Mang and Jon Camire just simply about stop-loss. But one of the things that you're talking about here is again, this kind of like rent seeking behavior in the healthcare sector is pervasive and it's really important to have antenna way up looking out for it. But if there is a broker or EBC who's recommending a stop-loss carrier, and then if you dig into it, what I think what you're talking about, we talked, we're talking about what do you audit?

You audit, you go through the plan documents, and then you see the plan documents are different than the stop-loss document and that there's a gap. Like, that is a sign there is a broker or EBC, I mean, maybe they were just ill informed or careless, right? Like, so what are they? What's that quote?

Never ascribed to malice. What could be explained by ignorance or something like this, right? Yeah. But like, so it could just be that this is complicated and which you know, in and of itself is good information.

But it also could be that that stop-loss carrier was being recommended because the broker or EBC is being paid. The fifth piece of advice in our roadmap is watch your own Defcon five reactions. Because Doug, you have told me earlier, there's enough examples of a plan itself who someone on the, the team at the plan heard something had kind of a Defcon five level reaction. And then because of that reaction, the vendor wants to serve the plan.

So if the plan is asking for something, maybe even demanding something, it may be like I had a mentor who used to say to me a lot, do you want me to tell you what you want to hear? Or do you want me to be a good servant? Exactly. As a vendor?

As an EBC. It's hard to tell a customer, No, I don't think you need that. No, I would agree with that a hundred percent. I would say in terms of the contract, I mean, you always have to have an out, without, you know, with cause I mean those auto renews.

And if you're not paying attention to it, I mean, you could be stuck for another 10 months and have to pay for the privilege to get out from underneath it. So just even going into the arrangement, you know, one year deals with a 90 day out. That's fair. So to your point, be careful what you ask for.

You may ask for something and then wind up signing a contract that then you can't get out of even after you come to your senses. Yeah. But it also is kind of, if you are working with a broker slash EBC with a clear contract, right? Like there's a flip side to all this.

If you go through and you're asking all these questions, you ask why five times? You look at those plan documents, they're simple, right? Like, and everything is starting to check out. And if that EBC or broker tells you you don't need this, then there's a good chance you don't really need it.

Take it to face value. Keep on moving. Yeah. And then our last one is trust but verify.

Like you hear so often, you look across these lawsuits. The average term of the broker or EBC with the plan that wound up turning around and suing for really egregious stuff is what I would consider long time. Having an EBC or a broker for a long time, you, you might really want to trust them because obviously you've got a long relationship with them, but a long relationship doesn't equal trustworthy without verifying. Could be the worst thing that ever, I mean, best thing that ever happened, but worse thing that ever happened.

Because find out what's really been going on. I just, I mean, I think truly, I mean, when you look at these lawsuits, I mean, I think a, I think the broker community is that substantial risk? I mean, there's a ton of good brokers out there, and I know a lot of them are my good friends. But it's just, unless you're adding real value, I don't know.

It could be, it could be a diff that could be in a difficult spot. In the trust but verify category also, I know one of the things that you've often had your eye on is just the entrenchment sometimes of, of public school districts, municipalities. There are the Osceola County lawsuit, right? Like there's a bunch of different lawsuits that have to do right now, the New Jersey case with the entrenchment of vendors with public entities.

Well, South Texas probably is the worst. I mean, you get down in the valley, a lot of the school districts, municipalities, tax supported entities, the broker relationship is because of political patronage and you start looking at the fees and everything else like that. It's just unbelievably crooked and wretched and it's, it's not an easy thing to get rid of. Yeah.

So in our kind of trust but verify category, you wanna trust the, the commissioner's neighbor's, brother, sister is in fact not run seeking. But yeah, so. Our last in our roadmap here is, is trust but verify. So we've talked a lot about what the problems are that can develop if we do have a rent seeking broker, a rent seeking EBC just kind of all the havoc that and the dollars, just millions that can wind up in their pocket.

Then we went through a roadmap of five things to really think about. And let's just end on a high note here because there are plenty, especially who listen to this show of amazing brokers who are doing the right thing by their clients and plan sponsors. They have easy to read contracts, their fees are disclosed. You can have a substantial impact simply by working with somebody who truly understands, you know, that market.

Absolutely. And, and on the flip side, underlining the advantages that a good broker can bring, I was just talking with someone who, immediately found three or $400,000 extra a year that was being charged for. Listen to the show with Andreas Mang also earlier about what a good broker kind of, or EBC brings to bear. You just gotta find the right person.

Doug Aldeen, if anyone is interested in learning more about you or your work, I would highly recommend that they follow you on LinkedIn. Thank you, Stacey. Doug Aldeen, thank you so much for being on Relentless Health Value today. I appreciate it very much.

I enjoyed talking to you. It's been great. Hi, this is Tom Nash, editor and producer of the Relentless Health Value Podcast. I bet you're wondering, how can I help Relentless Health Value?

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