What is site of care navigation, and does it actually save money?

One of the biggest levers left untouched in claims management is the site of care your employees use.

For the exact same procedure, the price the plan pays can vary drastically depending on the type of facility and the hospital system. A procedure done in a hospital outpatient department usually carries a facility fee that the same procedure at an independent imaging center or ambulatory surgery center doesn't. Your employee has no idea. Their doctor sends them to the hospital down the street because that's where the doctor has privileges, or because the hospital owns the practice.

Navigation fixes that. When an employee needs imaging, a non-emergency procedure, or a specialist, a navigator compares in-network options on price, quality, and convenience, and helps book it. The best programs reach out proactively when a referral or prior authorization comes through.

Employees don't change behavior for a brochure. They change it when it's easy and there is something in it for them. If the plan saves $2,000 on an MRI, paying the employee $200 to choose the cheaper site is an easy decision.

There are plenty of standalone vendors, and many TPAs now have steerage programs built in. Either way, hold them to measured results. Be skeptical of savings reports that assume every navigated claim would have gone to the most expensive option.

If you've been told claims are claims and there's nothing you can do, it's time to get granular and double check that assumption before you sign another big increase.

Questions to ask

What share of our imaging, labs, and outpatient surgery happens in hospital-owned facilities today?
Does our TPA or carrier have a steerage program we are not using?
How will savings be measured, and who audits that number?

What is direct primary care, and does it work with an HSA?

Direct primary care gives employees unlimited access to a primary care doctor for a flat monthly fee, with no copay. The value is downstream, keeping people out of the ER and the hospital. Starting in 2026, DPC no longer disqualifies an employee from an HSA as long as fees stay at or below $150 a month for an individual or $300 for a family.

How do underwriters actually price our renewal?

Your renewal is a number the carrier decides, not one it simply calculates. The underwriter projects your claims, adds trend, blends in a manual rate based on credibility, applies pooling charges for large claims, then adds retention for admin, taxes, commissions, risk, and profit. Every one of those inputs has a range, which is why two carriers can look at the same data and come back 15 percent apart.

When should we start working on our health plan renewal?

Five months or more before the effective date. Requests for quotes typically go out three to four months before renewal for fully insured groups and four to five months out for self-funded and captive groups, because stop loss quotes and lasers depend on current large claim detail. Most renewals fail because they start 60 days out.