Issuu

S EP T EMB E R 2 0 2 6

A S I P C P U B L I C AT I O N

SIPCONLINE.NET

Shoring Up Payment Integrity Greater movement seen toward pre-pay validation as AI helps reshape provider fees and due diligence

Accident & Health

At the heart of expecting the unexpected

Get the peace of mind and support it takes to self-fund your healthcare. Self-insuring your healthcare benefits can open up new possibilities for your business — affording greater flexibility in how you manage your healthcare spend. Trust the expert team at QBE to tailor a solution that meets your unique needs. Rated “AA-” by S&P, we offer a range of products for protecting your assets, your employees and their dependents: • Medical Stop Loss • Captive Medical Stop Loss

Read now: 2026 Accident & Health Market Report For more information, scan the QR code or visit qbe.com/us/msl

• Organ Transplant We’ll find the right answers together so no matter what happens, your business is prepared.

Specialty | Commercial | Crop Ratings as of 1/26/2026. All products and services are written or provided by QBE Insurance Corporation or its affiliates, 10 Terrace Court, Madison, WI 53718, and may not be available in all states. QBE and the links logo are registered service marks of QBE Insurance Group Limited. © 2026 QBE Holdings, Inc.

TABLE OF CONTENTS

SEPTEMBER 2026 VOL 214

W W W. S I P C O N L I N E . N E T

F E AT U R E S 4

SHORING UP PAYMENT INTEGRITY

Written By Bruce Shutan

PRIVATE EQUITY INVESTMENTS CONTINUE TO SHAPE THE HEALTHCARE INDUSTRY Written By Laura Carabello

ARTICLES 38

NATIONAL CONFERENCE – FEATURE SESSION PREVIEW

PBM PUGILISM Written By Bruce Shutan

DOL PROPOSES NEW ELECTRONIC DISCLOSURE FOR GROUP HEALTH PLANS

FEDERAL SURPRISE BILLING FINAL IDR OPERATING RULE – THE SIIA ANALYSIS Written By Anthony Murrello

MEMBER NEWS

Written By Alston & Bird Health Benefits Practice

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681, (888) 394-5688 PUBLISHING DIRECTOR Bryan Irland, SENIOR WRITER Bruce Shutan, CONTRIBUTING EDITORS Mike Ferguson, Jennifer Ivy, PRESIDENT/CEO Erica M. Massey, CFO Grace Chen

SEPTEMBER 2026

F E AT U R E

Shoring Up

Payment Integrity

Greater movement seen toward pre-pay validation as AI helps reshape provider fees and due diligence Written By Bruce Shutan

ayment integrity is increasingly being used to help self-insured employers comply with laws and become better stewards of the benefits they offer. With more self-insured employers struggling to manage their health plans, a more proactive vs. reactive effort to rein in high-cost claims has taken shape. A recent report by PwC recommends that payment integrity shifts upstream to validate high-risk claims before payment is made rather than relying primarily on post-payment recovery. In pushing a prepay solution for payment integrity, the approach is built around the proverb that an ounce of prevention is worth a pound of cure. Some vendors acknowledge that reference-based pricing has been perceived as a blunt instrument for pricing claims that can trigger acrimony and litigation. They also realize that tying payments to a percentage of Medicare, notorious for underpaying providers, is just a single data point, says Eric Hanna, EVP of payment integrity for Vālenz Health®. “We can look at Medicare as a reference point. We can look at usual, customary and reasonable data sets, and we obviously have our own data through companies that we’ve acquired such as Healthcare Bluebook,” Hanna explains, noting that all these different types of data sets can be aggregated or blended together. Vālenz has developed a market-sensitive repricing and compliance solution using multiple data points to generate what it describes as defensible reimbursement rates. Mindful that NSA regulations created a heavy burden for TPAs and their clients, it has delivered an average 15% IDR win or withdrawal rate. 4

THE SELF-INSURER

Shoring Up Payment Integrity This approach allows for flexibility when shifting from a more expensive market like California to less expensive markets in Oklahoma City, Indianapolis, or other regions. “Providers either don’t appeal, or if they do, we’re able to resolve it fairly quickly with very little additional payment,” he says. Prepay is where rubber meets road in payment integrity, according to Hanna. While providers prefer post-pay reductions, he says plans want to prepay over having to shuttle the dollars out and wait 90 days to get them back. “If you look at a prepay bill review vs. a post-pay recovery bill review, it could be the same provider, and the success rate of your discounts at the end of the day with the savings that you get are about 50% less on the post-pay side, and it could be the same example,” he says. In viewing payment integrity from a prospective lens, the idea is to lower claim costs before they’re even incurred. The reactive side is always difficult because the focus is on reducing something that’s already done, Hanna says. In other words: it’s about damage control. Then again, what constitutes payment integrity may be highly subjective. “It’s a word that if you ask 10 people, you’re going to get 10 different answers,” he quips. “I see the same thing with [the meaning of] quality in this industry.” NEW RULES OF ENGAGEMENT

Angel Onuoha

With the recent advent of largelanguage AI models, Avelis Health CEO Angel Onuoha references two exciting developments on the payment-integrity side. They involve an ability to ingest summary plan documents on behalf of third-party administrators and then turn them into audit rules that can be run against the claims on both a prepayment and post-payment basis.

“This is super helpful because you actually get to see whether your claims are being paid in compliance with the contracts that you have set up,” he says. His firm has an AI call center that handles the entire recovery process for any errors that were identified through payment-integrity and audit processes, which allows for a massively scaled-up effort to chase after low-dollar requirements, especially for post-payment. Many companies will only go after claims that have a minimum of,

say, $50,000 or up to $10,000 because it’s difficult to recoup most of those dollars if too many errors are identified, he observes. In focusing on post-payment reviews, Onuoha notes that payment-integrity vendors have been able to take their time through a process that doesn’t require as much real-time modern technology. As such, that’s where historically most of them have chosen to devote their efforts and energy. However, he has noticed the conversation moving toward prepayment because it’s a lot less abrasive for providers and easier on the plan side, not having to convince providers why overpayments were found. HORROR STORIES

Along the winding and often treacherous road to preventing self-insured employers from overpaying claims, there’s no shortage of astonishing examples of just what might lurk in bill reviews. ClaimInformatics, which uses highly sophisticated AI-supported technologies to ensure claims are adjudicated correctly, found a multitude of alarming issues surface for a university client with a Blues plan. For starters, the plan was to process claims with CPT codes that were discontinued years ago. While familiar with AMA’s CPT code set requirements stipulating that claims submitted with discontinued codes face SEPTEMBER 2026

Shoring Up Payment Integrity automatic denials rather than processing delays or conditional payments, the carrier denied the findings. It stated that the CPT was still valid, even though the CPT code was discontinued in January 2023. As careless as that practice was, it paled in comparison to an even more egregious discovery that was made. When ClaimInformatics identified anatomically impossible claim processing errors, such as hysterectomies billed for born males with no uterus, the payer’s legal counsel responded that it “do[es] not apply edits for gender specific codes. Based on legal review, gender editing would be considered discriminatory for transgender patients.” The client and broker were noticeably concerned and frustrated, recalls Stephen Carrabba, Co-Founder and CEO of ClaimInformatics, whose tool also detects ERISA and CAA violations through their contract compliance review tool. “For them not to adjudicate claims based on medical impossibilities is just a complete dereliction of duty on multiple fronts,” he says. “Even if I was born a male and transition to a female, I cannot have a hysterectomy.” He has seen a troubling pattern emerge across his book of business that even when errors are clear, carriers will not own them. For the same client, the payer argued it

“has been implementing multiple ICD10 requirements over the past year to improve correct coding requirements,” but declined the findings on the grounds that its technology had been subpar and was still improving. In yet another instance, the carrier conceded an error was real, then declined the finding because it had already paid itself to fix it through its own mistake and conflicted post-payment recovery program.

Stephen Carrabba

Of 107,000 claims ClaimInformatics reviewed on behalf of a captive in less than a three-month period, it denied $7.2 million at a 10.57% error rate after scrubbing claims deemed ready for payment after being repriced and adjudicated by the provider network. Carrabba says the errors were black and white. “We are not looking for medical necessity. We are not questioning the doctor. We’re not doing itemized bill review,” he reports. “A claim came in with the diagnosis of Type 1 and Type 2 diabetes. That is medically impossible. Period, end of story. This claim should have been denied.” Another red-flagged claim involved a physical therapist bill of $3,500 on the same day of a total knee replacement surgery, which is considered an all-inclusive procedure. “Day two? Absolutely fair game,” he says, “but you cannot bill for PT on the same day of the surgery.” A MATTER OF FIDUCIARY OVERSIGHT

Carrabba explains that this is exactly why every plan needs independent monitoring on every claim, whether prepay or, at the very least, post-pay. “It is not optional; it is a fiduciary obligation,” he explains. When the network is left to police its own claims, plan dollars get wasted, and no one is held accountable for how those claims are processed.” Noting that the fiduciary oversight issue is justifiably of great concern, he says independent TPAs and captives are no longer accepting the adjudication that comes out of provider networks as gospel. “They want an independent third-party review of the claims,” Carrabba notes.

SEPTEMBER 2026

Shoring Up Payment Integrity Using a payment-integrity solution can actually help a group health plan sponsor satisfy fiduciary duties under ERISA, according to SIIA’s Washington Counsel Chris Condeluci. However, he cautions that simply using one doesn’t absolve them from a potential lawsuit claiming a breach of their fiduciary duties. He referenced SIIA’s fiduciary must-dos checklist to help plan sponsors and their service provider partners better understand all that they should do to prove steps were taken to satisfy their fiduciary duties. Whether payment integrity is a standard operating procedure for selfinsured employers depends on the TPA, their size and how their systems are set up, explains Bruce Roffé, President and CEO of HHC Group and a licensed pharmacist, who believes there will be more pre-adjudicated claims audits in the future. Chris Condeluci

“I would think that those claims are already being scrubbed before it even gets to the payer, or if it gets to the payer, then their systems are weeding out the ones that just don’t make sense,” he says. There are four areas that Roffé says the TPA or payer will focus on: overpayments; underpayments; fraud, waste, and abuse; and billing errors and coding mistakes. His firm, which tackles the latter two categories, also serves as one of five independent dispute resolution entities for the state of New York under the No Surprises Act. As part of that work, which requires a clinical review under the state’s program – an effort that predates the federal effort – HHC Group determines whether claims charges are reasonable. TPAs can sometimes absolve themselves of the responsibility of checking for claim errors simply because it requires deploying massive teams and using better technology when they’re operating on tight margins, Onuoha observes.

Bruce Roffé

The prevailing thinking may be that without a payment-integrity engine, there’s less incentive to do that work and that their job is just to process claims. But he’s well aware that employers have taken legal action against their TPA and believes the issue will intensify. One such high-profile case involved a May 2025 decision by the U.S. Court of Appeals for the Sixth Circuit describing TPAs that control and profit from group health plan assets as fiduciaries under ERISA. Tiara Yachts Inc. had sued its TPA, Blue Cross Blue Shield of Michigan, alleging that it overpaid claims, then profited by retaining 30% of recovered funds as fees through a shared savings program. Complicating matters is the mass adoption of AI tools on the provider side doing revenue-cycle management, Onuoha notes, likening it to “combative technology.” That effort involves an attempt to find claims that were underpaid or denied and by doing any type of upcoding possible to maximize revenue. In fact, as many as 70% of health plans PwC surveyed ranked provider AI tools as one of their top three cost drivers for 2027. 8

THE SELF-INSURER

U N I VE R S I T Y

Shoring Up Payment Integrity “It shouldn’t really be one side vs. another side,” he says. “It really should just be both sides trying to get back and forth until we reach the ultimate truth of what actually happened on that claim and make sure it’s paid correctly.” PERCENTAGES VS. FLAT RATES

On another front, concern is mounting over the actual integrity of how much self-insured employers are being charged for paymentintegrity services to begin with. At a time of heightened awareness of price transparency and fee disclosure, Carrabba believes self-insured customers are tired of paying vendors a percentage of savings. “It’s all kind of a fictitious number,” he explains. “Is it gross? Is it net? You get into disagreements with clients. The reconciliations amass because they resubmitted and it turns out to be a disaster.” He cites a $300,000 charge for one particular payment-integrity solution, noting that irrespective of whether it’s an itemized bill review or otherwise, the profit margins are egregious. In pre-payment, his firm instead charges a per-claim fee, and if the claim is resubmitted, there’s no additional charge, with some clients seeing a 28:1 return on investment.

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for nearly 40 years.

SLASH CATASTROPHIC CLAIM COSTS BY UP TO 90%

See how much more you can save.

H.H.C. Group’s attorney-led negotiators deliver deeper discounts, verify billing accuracy and stop overpayment in its tracks. From large, complex out-of-network claims to high-dollar in-network hospital stays, we uncover savings automation can’t — and deliver them fast.

Contact H.H.C. Group today.

Don’t let excessive hospital and provider bills drain your bottom line

Real People. Real Savings.

240.813.6016 | sales@HHCGroup.com

“Independent payment integrity is here, whether the industry likes it or not,” Carrabba predicts. “Contracts are going to change. The tools that organizations like ours are building, coupled with great ERISA attorneys really pushing back, are forcing that change. This is what the market is now demanding from the Fortune 50 all the way down to 100-life plans.”

THE SELF-INSURER

Everything You Need to

Navigate the 2026 Benefits Landscape With the benefits market more complex than ever, brokers and their clients deserve better tools to navigate it. This comprehensive annual market report spans across the full spectrum of the benefits market providing actionable insights and data to you and your clients. Inside, you’ll find expert analysis on: – Economic & Regulatory Conditions – Market Trends & Insights – Carrier Insights – Technology & AI – Benchmarking Data – Best Practices & Strategic Renewal Approaches

Take a deeper dive into these insights and more in the full report. Available NOW!

Small to Mid-Market

Self-Funded

Ancillary

Exclusive Programs

Retiree Healthcare

F E AT U R E

Private Equity Investments Continue to

Shape the Healthcare Industry

Written By Laura Carabello

rivate equity's focused rollout across the American healthcare industry is one of the most defining and consequential business stories in recent memory. While the number of health services deals dipped in the first half of 2026, a midyear outlook report from PwC states that deal value has "remained resilient" as strategic acquirers and dealmakers "reprice risk." Analysts highlight how health services deal activity is evolving amid market pressures, emphasizing strategic focus, technology and portfolio optimization. Amid geopolitical dynamics, policy, reimbursement uncertainty and ongoing pressure from the “SaaS apocalypse,” the health services market is feeling the weight of skyrocketing costs, labor shortages and compressed margins. While deal volume softened in Q1 as investors demand more proof points before committing, total value remained strong due to large transactions. In the hospital space alone, by early 2024, private equity (PE) owned at least 386 hospitals — approximately 30% of all for-profit hospitals in the United States. What began as opportunistic investment in distressed hospitals has expanded into organized acquisitions of thousands of physician practices, urgent care chains, nursing homes, ambulatory surgical centers, emergency departments, hospices, behavioral health facilities, dental networks and more. The Private Equity Stakeholder Project (PESP) recently documented that more than 500 healthcare facilities have joint ventures with PE-linked companies and anticipates more of those partnerships to be announced. Additionally, in its latest quarterly M&A report, healthcare advisory firm Kaufman Hall tallied 18 new hospital transaction announcements from April through June. This momentum is well ahead of the eight logged in the same window last year and comfortably above the average posted by the sector across the 2020s. 12

THE SELF-INSURER

Private Equity Investments Overall investment dollars and transaction numbers for the broader healthcare marketplace are compelling: •

•

PESP reports that in 2025, PE firms completed 1,029 private equity-backed healthcare deals in the United States, consisting of 151 leveraged buyouts, 664 add-on acquisitions, and 214 growth investments, involving 420 platform companies and 708 investment firms. The most active healthcare subsectors they tracked included health IT (151 deals), dental care (149 deals), outpatient care (148 deals), medtech (117 deals), and behavioral health (56 deals). Home health and hospice, pharma services, and disability services also remained areas of notable private equity investment activity. Between 2000 and the present, the Center for American Progress reports that private equity investment in U.S. healthcare has grown from roughly $5 billion annually to an estimated $104 billion in 2024. PitchBook relates that elder care megadeals dominated Q1 2026 healthcare services PE activity.

Source: 2025 Private Equity Stakeholder Project As in prior years, PESP recounts that add-on acquisitions accounted for the majority of healthcare deals, reflecting private equity firms' continued use of consolidation strategies to expand platform companies. In addition to buyouts, add-on acquisitions, and growth investments, PE firms increasingly relied on joint ventures with nonprofit health systems as a growth strategy, providing access to established brands and geographic markets they might not otherwise readily access. A recent survey of leaders of private equity firms by McDermott Will & Emery and WSJ Intelligence, part of The Wall Street Journal, found that 40% of respondents had the most interest in investing in healthcare IT and telehealth in the next three years, followed by 37% interested in partnerships with large health systems. More than 30% were interested in investing in pharmaceuticals and biotechnology and physician practice management.

SEPTEMBER 2026

Private Equity Investments

Healthcare services PE deal count declined 16% YoY in Q1 2026 from robust Q1 2025 levels, though analyst expects volumes to improve as the year progresses. DEFINING PRIVATE EQUITY (PE) IN HEALTHCARE

PE is a form of for-profit ownership reflecting investment in healthcare facilities by private parties. PE firms use investor capital and borrowed funds to purchase healthcare facilities, with the goal of generating a high return on their investment by improving the facilities’ operations and increasing their value before reselling, typically within three to seven years. These acquisitions usually involve significant cost-cutting, management changes, and prioritization of revenue-generating services as key strategies to increase profitability and value. This short-term investment strategy is different from the strategies employed by venture capital firms, which typically invest earlier in a company’s lifecycle and take a longer-term approach. Source: 2025. The growth of private equity in US healthcare: Impact and outlook. NIHCM Foundation. Health policy analysts at the Arkansas Center for Health Improvement cite several reasons that the healthcare sector is an attractive investment area for PE firms: •

It is often viewed as “recession-proof,” meaning that healthcare systems are less vulnerable to the negative consequences of economic downturns than other industries because the demand for healthcare services will always exist.

SEPTEMBER 2026

Private Equity Investments •

Many types of healthcare services also generate predictable and high-volume revenue streams, particularly in outpatient settings such as urgent care clinics, behavioral health facilities, and specialty physician practices.

•

Many aspects of the healthcare sector have historically been fragmented into many small or independently owned providers. This fragmentation presents opportunities for private equity firms to consolidate these independent practices into larger, more efficient systems to generate increased revenue.

•

Regulatory gaps and limited ownership transparency have fueled the growth of private equity transactions in healthcare, allowing these transactions to occur with minimal oversight at the state and federal levels.

The debate over PE in healthcare is fierce, often partisan and rarely nuanced, as the cumulative effect on self-insured employers who bear the direct financial risk of their employee health plans is rigorous, measurable and accelerating. The typical PE playbook is consistent across specialties as industry pundits say the goal is to generate high returns for investors in the fund, not necessarily to build long-term value. In a fund’s portfolio, any one investment target need not survive in the end as long as the overall portfolio generates significant returns for its investors.

Trey Hinson, Founder, Goliath Sales Strategies, adds this perspective: “Any time you have an organization that gains a competitive position through acquisition or growth, they are going to push for increased reimbursements in this market or almost any other market. I think the maximization of profits, which has to be the goal obviously to your investors, adds to the efforts as well.” 16

THE SELF-INSURER

Accident and Health When it comes to specialty solutions for your clients

WE REDEFINE WHAT INSURANCE CAN BE A-RATED DIRECT-WRITING CARRIER MEDICAL STOP-LOSS COVERAGE GROUP AND SINGLE-PARENT CAPTIVE SOLUTIONS STRATEGIC COST-CONTAINMENT INITIATIVES INNOVATIVE, PARTNERSHIP-ORIENTED UNDERWRITING

Discover our unique approach & innovative solutions A SKYW

Contact

ah-sales@skywardinsurance.com

R D G ROU P COM PAN Y

Private Equity Investments With the continuing emergence of these high-performance networks though, there are options for self-funded groups, as he points out, “The largest problem for most TPAs is the effort that it takes to find the right broker distribution partners who are open to leaning into alternatives to the national PPO networks. This means as an industry, we must be stronger in presenting options and ensuring that our distribution channels can convey the reasons as to why this product fit may be stronger for some versus others.” PE CLOSES THE CAPITAL GAP

Trey Hinson

For those who live and work in the self-insured employer ecosystem, this influx of capital is not a distant Wall Street spectacle, as it is reshaping access, cost and quality of care in real time. Thoughtfully deployed PE investment can deliver genuine benefits to providers, payers and patients, particularly for self-insured stakeholders where flexibility and innovation are paramount. Early on, PE firms recognized the opportunity to address undercapitalization in healthcare. The provider sector was operating on razor-thin margins, facing diminishing and delayed reimbursements, outdated infrastructure and the specter of compliance requirements. As Rajiv Sood, General Manager, Insurance & Risk, Evidium, Inc., explains, “This isn't really a story about PE; rather, it's a story about what happens when clinical knowledge isn't computable. When no one can objectively define what appropriate care for a given patient should cost, pricing gravitates toward whoever holds the most leverage. At Evidium, we're focused on changing that foundation. When cost and clinical dynamics are transparent and traceable, patients, employers, and providers can engage in something closer to an honest conversation.” For the provider segments, this translates directly into resources that were not readily accessible through conventional debt markets. Many smaller Rajiv Sood entities lacked the financial position to invest in Artificial Intelligence (AI) technology or digital health to modernize and improve patient care, streamline daily workflows and optimize financial operations. PE capital solves this dilemma. Additional pressures on staffing ratios challenged even the most astute market performers. Research published in the Journal of Financial Economics by professors from Georgetown University and Indiana University reveals that PE-backed hospitals employ a higher ratio of doctors, nurses, and pharmacists compared to their non-PE counterparts. While PE acquisitions lead to overall workforce cuts, the core clinical workforce is prioritized. The American Investment Council (AIC) points out that, "Private equity provides healthcare companies with access to capital markets, lines of credit, pools of managerial skills and experience in turnarounds. This critical investment lets doctors, nurses, and other healthcare providers focus on patient care.”

THE SELF-INSURER

Today’s stop-loss market demands more than rigid structures that offer stock solutions.

Confidence to Think Creatively F E D E R A L L I F E I N S U R A N C E C O M PA N Y

At Federal Life Insurance Company, entrepreneurial thinking is driven by institutional experience, creative solutions are executed with discipline, and flexibility comes from reliability. Working with program administrators, TPAs, MGUs, brokers and intermediaries, our partnership-driven approach is built for program business today.

Fronting, Captives & Selective Risk Participation Structured for flexible program design. Easy to Work With Responsive, collaborative, and structured to keep programs moving.

125+ Years of Insurance Experience Disciplined execution backed by long-term stability. Stop-Loss–Led A&H Program Business Supporting modern group benefit strategies.

www.FederalLife.com •

Federal Life Insurance Company

For agent/producer purposes only – not for solicitation to consumers. Product availability varies by state and is subject to change. This material is intended for informational purposes only and does not constitute an offer of insurance. All insurance products are subject to underwriting approval and applicable regulatory requirements. Product terms, conditions, and availability may vary by jurisdiction. © 2026 Federal Life Insurance Company. All rights reserved. FLIC-SIIAAD-052726

Private Equity Investments

Source: 2025 Private Equity Stakeholder Project PE-BACKED ORGANIZATIONS ACHIEVE OPERATIONAL EFFICIENCY

The potential for PE to result in less paperwork, more care and reduced administrative waste is largely underestimated. A 2023 estimate from the Center for American Progress acknowledged that PE firms can relieve healthcare providers of administrative responsibilities, infuse capital, enhance revenue cycle management and introduce operational efficiencies. For plan sponsors, administrative efficiency in provider operations is not merely a clinical concern; it is a direct cost driver. Cleaner claims, faster processing, lower error rates and better documentation reduce friction across the entire payment chain. Sood believes there's a version of PE in healthcare that actually works for patients, for providers, and for the long-term investor, and it looks like this: using data and computational intelligence to identify where better care today prevents a catastrophic cost tomorrow.

THE SELF-INSURER

Private Equity Investments “The problem is that most operators are still making staffing and resource decisions with tools that can only see last quarter, not next year,” he states. “Clinical quality and financial performance aren't in tension; they're actually the same variable measured at different points in time, and that's the insight we're operationalizing. When a PE-backed operator can project a patient's clinical trajectory in real time, they stop seeing care investment as a cost center and start seeing it for what it actually is — the single most effective cost containment strategy available.” SALVAGING, REVITALIZING

AND STRENGTHENING HEALTH SYSTEMS

PE investment has repeatedly performed economic and operational rescues, stepping in where other capital sources have failed to preserve jobs, maintain services and keep facilities open in communities that would otherwise lose access to care entirely. Systemic overhauls that reform, restructure and transform the health system serve to stabilize the health system network and modernize patient care. As an example, the 2010 conversion of the Caritas Christi Catholic hospital system in Massachusetts into Steward Healthcare under Cerberus Capital's ownership was cited for years as a model of PE rescuing near-bankrupt institutions and

maintaining community services. For rural and underserved communities, AIC reports that PE-backed staffing companies have used growth capital to scale nurse and healthcare professional deployment in markets chronically short of clinical talent. Furthermore, in behavioral and mental health, one of the most critically undersupplied specialty areas in American medicine, PE has funded expansion. In fact, one report found that 60 percent of all PE deals since 2018 have involved behavioral health organizations. In a recent study examining the distribution of PE-owned behavioral health facilities, 6.2 percent of mental health agencies and 7.1 percent of substance use agencies were owned by PE firms. Some states, such as North Carolina and Colorado, reported 25 percent of their behavioral health facilities as privately owned. In another study published in JAMA Psychiatry, PE firms claim to be investing in the behavioral health sector for the purpose of fixing the broken system. Beyond behavioral health and substance use facilities, the American Psychological Association reports that PE firms have also purchased behavioral health technology and apps which can bring mental health treatment to more individuals, including persons living in rural areas. Reflecting on this pressing need, Trevor Colhoun, CEO, TPN.health, the operating system for behavioral health, says, "Private equity's role in healthcare is a net positive when success is measured the right way. Trevor Colhoun These investments push the industry toward better efficiency. In behavioral health specifically, it's injecting real energy into a space that's needed it for a long time." Invigorating provider entities with capital infusions matters enormously for self-insured plans and their members. It is especially important for employers that operate in regions where specialty access is severely limited, and their employees face longer wait times, challenges that result in delayed diagnoses and greater reliance on expensive emergency services. PE-backed consolidation of service providers can meaningfully expand in-network options for plan members, reducing out-of-network exposure and the downstream claim volatility that afflicts self-insured plans. SEPTEMBER 2026

Private Equity Investments But many analysts concur that the reason hospital prices are so high is hospitals’ accumulation of market power, which brings them more bargaining power when they negotiate prices with insurers. The Department of Justice (DOJ) and Federal Trade Commission (FTC) use the Herfindahl-Hirschman Index (HHI) to measure hospital market concentration, where >1,800 is highly concentrated, 5,000-7,500 is where a few firms hold substantial market power, and >7,500 is a near monopoly, where a single firm holds absolute (or near absolute) price-setting autonomy. The hospital market is heavily concentrated and has an average HHI score of 5,273, with 97% of markets being at least heavily concentrated and 64% being near or complete monopolies. From Sood’s perspective, “When clinical dynamics are computable and transparent, consolidation that truly improves care gets rewarded by patients who trust it, by employers who choose it, and by a market that can finally see the difference. The PE firms that lean into that transparency will have a durable competitive advantage. The ones that depend on opacity are building on borrowed time.” VALUE OF HEALTH IT INVESTMENT

Management consultants at Bain and Company attest that healthcare IT remains a top-performing segment for investors, outpacing the rest of healthcare and most other industries. Deal volumes have remained robust, accounting for nearly 20% of healthcare transactions in 2025 compared with 15% in 2021, underscoring increasing investor interest. Emerging technologies offer opportunities to streamline backend processes to achieve cost savings and facilitate new product development to drive revenue expansion. Advisors maintain that leading investors are achieving ‘Rule of 60’ outcomes, an evolving financial benchmark used primarily in the AI and Software-as-a-Service (SaaS) industries. It states that a highperforming company's combined Year-over-Year (YoY) revenue growth percentage and Free Cash Flow (FCF) margin should exceed 60. Consistent, disciplined focus on value creation, from underwriting to exit, sets apart the highest-returning deals, with Generative AI offering top- and bottom-line value creation opportunities for healthcare IT providers. Incumbent health IT firms will likely have to add generative AI tools, or they could lose their market position to other AI-native companies. These investments are significant for employers as healthcare costs continue to rise amid a growing focus on alternative and tech-driven health plans to remain financially sound. Self-insured entities rely on these PE-backed solutions to optimize their bottom line without compromising employee health benefits. PE also fuels the growth of data and analytics platforms that help employers dig into their specific claims data. This visibility allows companies to identify cost drivers, forecast expenses, and prevent overcharges before they hit the balance sheet. Capital accelerates opportunities for buying or scaling cost containment vendors that use advanced software to reprice claims, audit medical bills for inaccuracies and apply outof-network solutions to lower hard-dollar medical spend. In addition, PE cash infusion optimizes pharmacy benefit optimization by supporting the development of robust software solutions that negotiate lower drug prices, track specialty drug utilization. and audit pharmacy rebates for greater transparency. These funds are also critical for building captive management software that helps employers manage catastrophic claims and optimize their stop-loss policies.

THE SELF-INSURER

Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together.

Experience exceptional customer service and top-tier stop loss coverage with Swiss Re Corporate Solutions. Our steadfast dedication to our clients ensures a seamless business experience. We streamline stop loss coverage, addressing industry challenges to help move you forward. Discover smarter, faster and better stop loss solutions tailored to you. corporatesolutions.swissre.com/esl

Private Equity Investments

Source: Bloomberg, data as of 1 January 2019 to 14 May 2026. Represents GICS sector market capitalization as a percentage of S&P 500 Index total market capitalization. Healthcare = S&P 500 Healthcare Sector, which comprises those companies included in the S&P 500 that are classified as members of the GICS Healthcare Sector. Technology = S&P 500 Information Technology Sector, which comprises those companies included in the S&P 500 that are classified as members of the GICS Information Technology Sector. Past performance is no guarantee of future results. VALUE-BASED CARE ALIGNMENT

As PE investors focus heavily on tech-enabled platforms that transition care toward value-based models, they are enhancing the capabilities of companies providing virtual health/telehealth, chronic disease management and primary care networks that lower costs by keeping employees healthier and preventing emergency room visits. Proponents of PE investments, including industry groups like the Medical Group Management Association, outline several benefits, including access to the necessary capital to upgrade aging facilities, expand into underserved areas and accelerate the development of life-saving medical technology. They tout operational efficiency, streamlining administrative overhead and integrating fragmented electronic health records that allow doctors to focus more on patient care. With an eye on market trends, many modern PE investments target value-based care platforms, incentivizing providers to focus on proactive preventative care rather than fee-for-service volume. The Bloom Organization commends this focus on predictable, value-based revenue streams, noting that practices that demonstrate consistent cash flow, strong patient retention and quality outcomes data are commanding premium valuations. This shift reflects broader industry trends where payor contracts increasingly reward outcomes over volume. But pushback from America’s Health Insurance Plans (AHIP), the lobbying group for insurance payers, is worth acknowledging. In a recent report, AHIP states that PE firms consolidate smaller healthcare entities to increase their market power and leverage in setting reimbursement rates with payers. AHIP regards 24

THE SELF-INSURER

Private Equity Investments this as a bad thing, pushing for federal scrutiny of even the smallest transactions, and portraying physician practice mergers as a threat to care. In fact, the main threat from these practice mergers is to the massive profits of healthcare payers, like the ones AHIP represents. AN HONORABLE CAVEAT

The case for PE in healthcare is real, but many thought leaders caution that it is not unconditional. As PE firms focus on short-term revenue generation and investor profit, this approach also can lead them to strip acquired facilities of their assets, force those entities to raise prices through anticompetitive practices, reduce staffing to dangerously low levels, avoid investment in critical infrastructure and eliminate vital services. Todd E. Archer, CEO, Concierge Third Party Administrator, believes, “The fundamental purpose of PE is to maximize the Return on Investment. A central component of that process (in most cases) is increasing billings either through unit cost increases and/or incremental billings for services. There is no way these increases don’t flow through to the patients and plans.” The other central component of any process to maximize Return on Investment is to minimize expenses, as he explains, “The largest single expense category for any business is labor, so it stands to reason that this is where the quickest returns will be generated. When the primary focus of any business venture is to maximize the bottom line (to the exclusion of all else), it will have a detrimental effect on the quality of the product being delivered. You might argue whether the degradation is short-term or long-term, but it will occur. “

A More Strategic Approach to Healthcare Risk

At Brown & Brown, we understand your priority is patient care, not insurance concerns. Our Healthcare team leverages industry knowledge to deliver tailored solutions across all aspects of the business Medical Professional Liability, Managed Care Risk, Reinsurance and Property, Casualty and Liability. The Brown & Brown Healthcare team is composed of experienced insurance brokers and risk financing consultants who provide global access to top commercial insurance carriers and specialization in alternative solutions analysis and administration. BBrown.com

SEPTEMBER 2026

Private Equity Investments Many stakeholders argue that PE stewardship and activities are detrimental to the patients, workers, and entire communities. For this reason, private equity fund ownership is concerning in the healthcare space, where quality of care and patient safety are in the public interest and should be a healthcare entity’s highest priority. Supporting this viewpoint, research from a systematic review conducted by the Columbia Mailman School of Public Health, which examined 55 studies, found that PE ownership was associated with increased costs in 9 of 12 cases and decreased costs in none. Other studies have specifically documented increases in the charged and allowed amount per claim following PE acquisitions of independent physician practices. Market perceptions persist that PE acquisitions increase negotiated prices that translate into higher costsharing for members and are ultimately passed on through taxes or suppressed wages for plan sponsors' own employees. The National Institute for Healthcare Management (NIHCM) Foundation, a nonprofit, nonpartisan organization dedicated to improving healthcare through evidence and collaboration, states that while PE investment in healthcare may improve operational or technological efficiencies, there are concerns about the effects on cost, quality and utilization of care. Studies specifically document increases in the charged and allowed amount per claim following PE acquisitions of independent physician practices. Dr. Bruce D. Roffé, P.D., M.S., H.I.A., President and Chief Executive Officer, H.H.C. Group, a healthcare cost containment firm he founded in 1995, cautions, “For healthcare payors, the rise of PE in this field presents significant challenges, including skyrocketing costs and diminishing care quality. Private equity firms operate on a straightforward yet aggressive business model: acquire assets, boost their perceived value, extract profits and eventually sell them off. In the context of healthcare, this approach often means prioritizing financial returns over the well-being of patients and communities.” Roffé says that by consolidating services and creating near monopolies in key areas like anesthesiology or emergency care, PE firms have the leverage to dramatically increase prices, and these inflated costs are passed along to payors, employers and patients. He describes their profit-driven culture shifts from patient care to bottomline metrics, eroding morale and quality of service. Bruce Roffé

“This cost-cutting ethos, while boosting short-term profitability, undermines the very foundation of effective healthcare delivery, jeopardizing patient outcomes and straining payer resources,” he observes. Roffé warns that one of the most alarming aspects of PE’s foray into healthcare is the absence of federal regulation to curb its practices: “Unlike other industries where antitrust laws and oversight can mitigate harmful consolidation and predatory practices, healthcare remains an open playing field for these investors.” He says the rising costs associated with PE involvement directly impact healthcare payors, increasing premiums and straining budgets for insurers, TPAs and self-insured employers.

THE SELF-INSURER

info@valenzhealth.com valenzhealth.com

Private Equity Investments “The ripple effect on healthcare payors is a significant challenge,” he continues. "PE-owned ambulatory surgery centers have been documented charging up to 50% more following acquisition — along with more aggressive out-of-network billing, upcoding that inflates claim values, and less pricing transparency." Hinson believes that when an organization gains leverage through acquisition or growth, they're going to push for higher reimbursements, adding, “That's true in this market and just about every other one. And when you've got investors expecting returns, profit maximization isn't a side effect; it's the mandate.” In response, many advisors suggest the self-insured ecosystem would be well served by a policy framework that distinguishes between PE investments that genuinely improve access and efficiency, and those that are principally designed to extract revenue through pricing leverage. That distinction is not a blanket condemnation or endorsement of PE; it is the point where productive policy conversation should begin. For providers facing a capital desert, for payers seeking operational partners capable of driving efficiency and for self-insured plan members who need access to expanded care options, PE in healthcare can be a legitimate source of value. The evidence for PE's contributions to health IT innovation, operational professionalization, and access expansion in underserved markets is genuine and documented. The question for the self-insured community is not whether PE belongs in healthcare. It is whether the structures governing PE investment transparency requirements, antitrust enforcement, network adequacy standards and dispute resolution rules are calibrated to maximize the capital benefits while containing the risks. It is essentially a regulatory challenge, not an indictment of private capital itself. CONFLICTING STUDIES SPARK DISCUSSION

PE may have generated some negative notoriety when a landmark 2025 study published in the Annals of Internal Medicine found that after PE acquisition, hospitals reduced emergency department salary expenditures by 18.2%, approximately $12.63 per inpatient bed stay. Non-PE hospitals, by contrast, increased pay in the same departments. The Harvard Medical School-led research team noted that PE hospitals transferred sicker patients at higher rates than non-PE facilities, suggesting the most complex and costly cases are being redirected rather than treated and linking staffing and salary cuts to a measurable increase in patient deaths. The study contends that these actions shift downstream costs onto other providers and ultimately onto plan sponsors. Another indictment surfaced in a 2024 report from the Stanford Law Review claiming that no study to date has found significant improvements to healthcare quality, efficiency, costs or access as a result of PE's entrance into healthcare. The researchers framed the trend starkly: the drive for rapid revenue generation threatens to increase costs, lower quality and contribute to physician burnout and moral distress. Yet an additional study found that not-for-profit hospice ownership was associated with the greatest spending on direct patient care services. By contrast, all for-profit ownership models spent significantly less on direct patient care, with PE-owned hospices spending the least. The study estimated that the difference in direct patient care spending between the not-for-profit and the three for-profit models was driven by spending on nursing salaries.

THE SELF-INSURER

of Strength You Can Count On For two decades, Berkley Accident and Health has helped organizations manage risk with strong protection and data-driven insights.

Built on financial strength

Proven through experience

A+ (Superior) rated and a member of a Fortune 500 organization1

Leader in Stop Loss, Group Specialty Accident, and Managed Care

Driven by insight Direct writer1 dedicated to innovation and transparency

Twenty years in, and we’re still focused on the future. To learn more, contact your Berkley Accident and Health representative or visit www.BerkleyAH.com.

Berkley Life and Health Insurance Company and StarNet Insurance Company are rated A+ (Superior) by AM Best. Berkley Accident and Health is a member of W. R. Berkley Corporation, a Fortune 500 company.

Stop Loss is underwritten by Berkley Life and Health Insurance Company and/or StarNet Insurance Company, both member companies of W. R. Berkley Corporation and rated A+(Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states. Payment of claims under any insurance policy issued shall only be made in full compliance with all United States economic or trade and sanction laws or regulation, including, but not limited to, sanctions, laws and regulations administered and enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”).

BAH AD 2025-231

www.BerkleyAH.com

Private Equity Investments Counterbalancing these reports, researchers at the Georgetown University School of Business observe that while in the first few years of takeover there is a reduction in both medical and non-medical workers, the number of medical workers quickly recovers and reverts back to pre-acquisition levels within five to eight years. However, the number of administrative employees does not recover, but permanently goes down. This reveals that PE firms do not seek to chase profitability to sacrifice longterm healthcare quality. Consistently, they do not find a significant change in patients’ mortality rates after the takeover. The American College of Surgeons PE extols investment into the healthcare sector, stating that it can result in positive changes regarding workforce shortages, increased access to resources and enhanced patient care. Specifically, PE acquisition can provide capital investment for start-up practices to purchase office space, equipment, and improved electronic health record processes, hire personnel and analyze big data to handle capitated contracts. But the jury is still out on quality of care, since many studies validate that patients treated in PE-owned hospitals experience more hospital-related adverse events, including bloodstream infections, surgical site infections, and falls. Perhaps most accusatory is the nursing home data: A 2023 study found that nursing homes owned by PE were associated with more than 20,000 additional resident deaths over a 12-year period. The National Institutes of Health's consolidated research summary is equally sobering: "Overall, research has found that PE involvement in healthcare has led to changes in the workforce, increased costs and utilization, mixed effects on quality of care and a lower percentage of Medicare patient discharges, implying an increase in privately insured patients with higher reimbursement rates." REGIONAL MARKET CONSOLIDATION

Regional consolidation is better known as a "roll-up" strategy in which PE firms serially acquire competing practices, group by group, until they achieve dominant market share in a specific specialty or geography. Because individual acquisitions are structured to fall below the Hart-Scott-Rodino Act's $119.5 million threshold for mandatory antitrust review, regulators frequently cannot see the full picture until concentration is complete. For self-insured employers operating in geographically constrained markets, PE consolidation draws criticism for eliminating the competitive alternatives that give TPAs leverage in network contracting. When there is only one PE-owned anesthesiology, radiology or emergency medicine group in a region, employers have no choice but to accept those providers' rates or leave their plan members without innetwork access. Federal and state regulators have responded. In 2025, the FTC, DOJ, and HHS released a joint report confirming. “The American public is dissatisfied with ongoing trends in the healthcare sector," with over 2,000 public comments documenting consolidation harms. The report noted that by 2024, approximately three-quarters of health insurance markets were considered highly concentrated.

THE SELF-INSURER

Private Equity Investments REGULATORY HEADWINDS

PE investment in the U.S. healthcare sector faces a complex and evolving regulatory and legislative landscape. Due to mounting concerns over stealthy consolidation and financialization, state and federal regulators are heavily scrutinizing PE transactions in 2026. At least 25 states have tracked or introduced legislation to increase ownership transparency, mandate transaction reviews, and curb anti-competitive practices in healthcare M&A transactions. Attorneys at Benesch law firm warn that both federal and state authorities are intensifying scrutiny of PE investment, driven by concerns about market consolidation, quality of care, corporate profiteering and lack of financial transparency. As challenges mount, particularly at the state level, PE firms and the healthcare businesses in which they invest must be prepared to adapt their consolidation strategies. While the current administration will likely take actions to spur PE investment and prioritize deregulation, some states could attempt to counterbalance the federal government’s approach with additional state regulations intended to address perceived gaps in federal regulation and enforcement. California, which recently enacted legislation that grants the state greater authority to scrutinize PE investments in healthcare providers, as well as Massachusetts, Oregon, and a handful of others, have enacted similar laws. PE firms with healthcare portfolios should expect increased state-level compliance obligations, longer transaction review timelines, and more public scrutiny around outcomes. But PE ownership can deliver a compliance uplift for self-insured plan sponsors and their TPAs, as Managed Healthcare Executive has reported: "The capital from PE can also help providers adhere to government rules, take steps to reduce fraud and abuse and improve billing. Private equity typically will raise the bar on compliance." Authors forecast that for stop-loss carriers and TPAs negotiating in an era of increased regulatory scrutiny -- from the Consolidated Appropriations Act's transparency requirements to CMS enforcement of surprise billing rules -- a provider community with stronger compliance infrastructure will mean fewer disputed claims, cleaner audits and more predictable payment processes. SAFEGUARDING AGAINST RISKS

Writing in the May 2026 edition of the American Journal of Managed Care, thought leaders contend that PE’s growing influence on American healthcare has outpaced regulatory oversight and call for stronger policies to safeguard patients, providers and care delivery. Authors maintain, “There is growing political will for reform, driven by regulators who have recognized that PE’s outsized footprint makes it an urgent target for policy intervention…robust policy must, at a minimum, shield patients, providers and practices from PE’s associated risks, and, at best, position these parties to benefit from private investment.” Their recommendations include: •

Empower antitrust authorities and strengthen existing policies to increase accountability, promote competition, and curb consolidation.

•

Pursue novel regulatory solutions, including healthcare–specific PE law, alignment of state and federal oversight, adoption of alternative payment models, and strengthened patient protections against PE-associated risks. SEPTEMBER 2026

Private Equity Investments •

Learn from international policymakers who have embraced PE oversight through models that enhance transparency and regulate financial arrangements.

PE TANGLES WITH THE NO SURPRISES ACT

Passed in 2020 to shield patients from unexpected out-of-network bills, the No Surprises Act (NSA) created an Independent Dispute Resolution (IDR) process for payment disputes between providers and payers. While regulators projected approximately 17,000 disputes per year, the reality has been catastrophic for employers. The Texas Association of Health Plans reports that from mid-2022 through May 2025, 3.3 million IDR disputes were filed – more than 190 times the projected annual volume. In 2024, 39% of all disputes filed were identified as ineligible under the law, yet health plans were forced to pay out nearly half of those ineligible claims. PE-backed providers have been identified as the engine of this dysfunction. •

In 2023 and 2024, 43% of all resolved line-item IDR claims were filed by just two PE-backed organizations: Radiology Partners and TeamHealth.

•

KFF's analysis of IDR performance through mid-2024 found that the top 10 dispute-initiating parties are all providers or their billing consultants, and the top three parties -- all of which are backed by private equity firms -- accounted for 53% of payment disputes from the beginning of 2023 through mid-2024.

•

Congressional Research Service documents that for air ambulance services, another specialty dominated by PE-backed operators, Global Medical Response, Air Methods, and Apollo MedFlight collectively initiated 65% to 72% of all disputes in each quarter of 2024. PE-backed providers typically win the disputes. A Health Affairs Scholar study analyzing 2023 emergency medicine IDR data found that providers won 86% of cases overall, with mean decisions averaging 2.7 times the qualifying payment amount (QPA). PE-backed providers won more often and with higher monetary awards than other providers, with PE-backed physician staffing companies winning 90% of their disputes.

Christine Cooper, CEO, aequum LLC, who serves on the Self-Insurance Institute of America's Board of Directors, emphasizes, “The No Surprises Act dispute process was not designed with high-volume, PE-backed operations in mind. The extraordinary volume was overwhelmingly driven Christine Cooper by a handful of PE-affiliated providers and revenue cycle companies. The practical consequence is that self-insured employers are absorbing billions in awards that are well above the in-network and QPA rates. Employers who focus on eligibility and methodology rather than individual claim outcomes are better equipped to navigate this overburdened process.” For those who question why PE wins so consistently, KFF explains, “PE-backed provider groups have historically been able to negotiate for above-average contracted rates," and those prior contracted rates become evidence in IDR proceedings that arbitrators are required to consider. The roll-up strategy creates pricing leverage in network contracting, which becomes the basis for winning above-median awards in SEPTEMBER 2026

Private Equity Investments arbitration. In the process, the costs are borne by self-insured plan sponsors, their TPAs and ultimately their employees. There is growing sentiment that PE is pursuing arbitration as a business strategy. The Niskanen Center Think Tank lays blame on arbitrators that consistently side with providers offering rates several times higher than insurers’ median in-network payments, resulting in the current IDR framework that creates strong incentives to flood the system with disputes. They say PE-backed provider groups, in particular, are well-positioned to exploit this dynamic: they are highly motivated to generate quick revenue to meet debt obligations and have the financial capacity to absorb arbitration fees. As a consequence, dispute volumes have vastly exceeded predictions and the IDR system, originally designed as a last resort for genuine disputes, has been transformed into a revenue optimization engine. For self-insured employers, it may not be acceptable to remain passive victims in this landscape but to initiate strategic, coordinated action that can materially improve plan outcomes in NSA disputes and limit PE's leverage over benefit costs. Hinson expresses that the NSA took the patient out of the crossfire, and credited where it was due. “But the IDR process has become its own arena, and PE-backed groups treat arbitration as a revenue strategy, not a last resort,” he explains. “We are struggling to defend the reimbursement protocol, and the PEbacked physicians are enhancing resources to make sure the judgments go their way. As an industry, we must look at this much more aggressively, as treating it as an administrative headache is simply causing most entities to fail in the independent reviews. What will it take for employers to prevail? Showing up

N AT I O N A L S T R E N GT H . LO CA L E X P E R T I S E .

When the Market Gets Stormy, Stability Matters. Mergers & Acquisitions. Service Disruptions. Shifting Partnerships. Now more than ever, your clients need a TPA partner they can count on.

90 Degree Benefits gives brokers a stronger foundation in an uncertain market. Self-Funding Unique funding options designed to control costs.

e Scan to se rs why broke e th g in are mak rn right tu .

THE SELF-INSURER

CareConnect Advocacy Personalized support to help members make more informed healthcare decisions.

Network Solutions PPO, EPO, and RBP HighPerformance options for improved access to care.

Let’s build a smarter benefits strategy Join the thousands who trust Nationwide® to deliver valuable employer solutions. Our expert teams can help build a better self-funded, cost-containment strategy that delivers meaningful and comprehensive benefits to employees.

Why work with Nationwide®? Experience We have over 20 years of experience in the self-funded, stop loss and voluntary benefit spaces

Partnership and support Our teams and partners provide personal and professional support to agents, employers and employees

Customizable You can tailor plan designs to meet the needs of small to midsize businesses

Get support and expertise where you need it most. Learn more at nationwide.com/grouphealth.

The Self-Funded Program through Nationwide provides tools for employers owning small to midsize businesses to establish a selffunded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. Stop loss insurance policies are underwritten or reinsured by Nationwide Life and Benefits Insurance Company. Refer to nationwide.com/ stoplossdisclaimer for details. Product availability and specific provisions may vary by state. Nationwide and the Nationwide N and Eagle are service marks of Nationwide Mutual Insurance Company. © 2026 Nationwide GHM-0349AO (06/26)

Private Equity Investments prepared and collectively working together to fight for fairness and leaning into the robust data set we have. Our partners and clients depend on us to take this approach.” Archer contends that things are not going to change in that process, “…until the transparency movement is able to expose the egregious billing practices being used in a manner that is easily accessed and understood by the rank-and-file employee.” Sood considers that the No Surprises Act got the patient protection right, with this caveat: “Where it fell short was in anticipating that a small number of highly consolidated, PE-backed provider groups would treat arbitration not as a last resort but as a core revenue strategy — and that the information advantage built through years of roll-up acquisitions would translate almost directly into IDR wins. There's a better version of this system available, and it doesn't require dismantling the law. It requires giving employers, patients and plans the same quality of clinical and financial intelligence that sophisticated provider groups already have.” He clarifies, “When the cost of a patient's care can be grounded in their actual clinical trajectory, and not just comparable rates, arbitration becomes what it was always supposed to be: a genuine dispute resolution process, not a revenue optimization engine. That's the system patients deserve, and it's the one we're working to make possible.” THE VALUATION OUTLOOK

While technology, media and telecommunications participants lead the outlook for valuations in 2026, healthcare lags at the other end of the spectrum. A Citizens Bank survey provides this intelligence: just a quarter of respondents anticipate higher valuations in 2026. The majority expect valuations in healthcare to remain stable, possibly reflecting an already-high level from 2025.

Source: 2026 Citizens Bank

THE SELF-INSURER

Private Equity Investments While venture capital investment across the healthcare sector slowed in the first half of 2025, investors are spending on health tech — especially artificial intelligence (AI). The Silicon Valley Bank (SVB) reported that last year, the segment made up about one-third of overall healthcare investment, with just over 60% of health tech funding linked to companies that use some form of AI. According to SVB, back-office use cases for AI have become a large focus for investment since their processes are outdated and ripe for disruption. Tools aimed at lessening administrative work rather than clinical tasks made up 44% of AI funding. Fast forward to the SVB 2026 Healthcare Report and commentary from David Crean, Ph.D., managing partner, Cardiff Advisory, who characterizes AI as “One Theme Consumes Half a Market.” He projects healthcare AI to reach $22B, which equates to 46% of total healthcare venture capital.

Source: 2025 Private Equity Stakeholder Project

Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com

SEPTEMBER 2026

SIIA NATIONAL CONFERENCE –

FEATURE SESSION PREVIEW

hether you are contemplating a financial transaction now or in the future and will be attending SIIA’s upcoming National Conference, please consider attending the “Financial Transaction Landscape for the Self-Insurance Marketplace” session, which features a panel discussion with some of the leading investors in this space. Chairing this session, Spike Dietrich, Ansley Capital Group, shares, “Investor interest in the self-funded marketplace has increased significantly over recent years and shows no signs of slowing down. The size of the market has put a bullseye on our SIIA companies: 63% of all employer-provided healthcare is selffunded. This growth has fueled investor recognition that the rapidly rising healthcare costs for employers have focused even more market attention on companies whose mission is to contain these accelerating costs. A combination of these factors is clearly evidenced by the fact that many of these companies receive investor outreach calls several times a week.” He says that for many SIIA companies this level of interest, while positive, also raises questions and often creates confusion as leaders express these concerns:

THE SELF-INSURER

"I understand healthcare, I have a vision for a company that will help control costs, and my team and I know how to build this company. What I don't understand is the investor angle: who to believe, who to talk with, and what type of deal will be right for us. I hear about good outcomes with some deals and horror stories with others." Dietrich continues, “The upcoming session in Phoenix, Financial Transaction Landscape for the SelfInsured Marketplace, has been designed to address many of these concerns and realities. We have four of the nation's leading healthcare-focused investment banks and have structured this session to address these concerns while also providing an updated look at how investors are currently viewing this market.” Panelists preview discussion highlights as follows: •

Jeff Swearingen, Managing Director, Edgemont Partners, observes, “Every self-funded employer is facing the same challenge: cost trends projected at 6.5 to 9 percent annually with no end in sight, alongside heightened fiduciary obligations. These pressures require companies to prove their plans are well managed and, ultimately, are driving the demand side of deal flow.”

Across Edgemont’s Payor Services and Technology practice, Swearingen and colleagues see sustained strong private equity demand for TPAs, payment integrity, cost containment, and pass-through PBM models -- the vendors employers rely on to control spend they can no longer absorb. “Additionally, we believe vendors that increase data access and offer services in a price-transparent model will continue to capture market share,” he adds. During this panel, Swearingen hopes to show attendees how investors evaluate the companies serving self-insured employers, what investors value and will pay for, and where Edgemont Partners sees the most compelling opportunities for investment and consolidation. For the session, Brian Thomas, Managing Director, TripleTree, articulates a few goals: •

Provide more color regarding the themes driving investment activity

•

Outline the considerations sponsors evaluate when pursuing investments

•

Highlight items business owners should prepare for when pursuing private equity investment

•

Discuss key factors to consider when evaluating a private equity partner

“The private equity investment environment within the employer benefits sector is robust, as financial sponsors are attracted to the sector's durable market tailwinds,” says Thomas. “Firms are investing behind several themes, fundamentally focusing on solutions that produce an objective ROI, reduce administrative burden, or create a better employee experience. We expect to continue to see enthusiasm towards investing behind uniquely positioned point solutions as well as vendors pursuing a broader platform strategy that encompasses administrative, underwriting network and care activities.” •

Echoing the frustration that employers have experienced for decades with rising healthcare costs, Nick Owens, managing director, Harris Williams, asserts, “What has changed in the market over the past 18 months is growing awareness of the structural challenges with the traditional health insurance model and a willingness to adopt new alternative health plan solutions that are memberand employer-centric vs. the traditional network-centric model. This creates a massive opportunity for SIIA companies that enable the transition to self-funding and support the ability to drive cost savings, which correspondingly have driven unprecedented investor interest in the space.” SEPTEMBER 2026

•

There are several reasons why interest in this self-insured market is accelerating so rapidly, as Trey Marinello, Managing Director, Houlihan Lokey, explains, “The confirmed shift toward risk taking is neither novel nor new, but it is innovative as this trend moves down market. The most attractive assets in this category are companies that are serving smaller employers, less than 50 lives.”

Marinello also points to the surge in artificial intelligence (AI) and its impact on deal-making. “Everyone in every industry is talking about AI and its role in more than half the private equity deals, including those in the self-funded space,” he continues. “The first question that private equity committees pose is how AI is impacting a particular business model. While we can’t predict what AI can actually do in any market, we do know it plays an important part in employer-sponsored plans.” As employers face a 15% or more increase in healthcare costs, Marinello notes, “AI can support decisionmaking regarding the choice of alternative models to manage costs – self-insurance, level-funding, ICHRA, Medical Expense Reimbursement Plan (MERP) or other. As PE cools off on providers, post-acute care, distributors or other opportunities, they are driving forward in the employer-sponsored healthcare space. Tools to mitigate costs are generating the highest level of attention.” MARK YOUR CALENDAR

The session is scheduled for Tuesday, October 13 from 10:15 a.m. to 11:30 a.m. Detailed event information can be accessed at www.siia.org

Expertise,

Not Just Execution. Placing a self-funded plan takes execution. Managing one well takes expertise. CRC's Self-Funded Division brings actuarial, clinical, and claims expertise to operate as a genuine co-pilot on the account, not a back-office vendor. Advisors don't need a partner who places the business. They need one who helps win it.

THE SELF-INSURER

SEE YOU AT SIIA NATIONAL CONFERENCE Join Prudential for conversations and cocktails at SIIA National Conference! • October 13 • 11 am – 5 pm • Twenty6 bar, located in the lobby of the hotel Come chat with us to learn more about our stop loss offering and help us create the full picture to win a prize and a ticket for a free drink!

Please visit our Stop Loss Insurance page for more information.

Prudential Stop Loss policy options may vary by state. Contact your Prudential representative for more information. Group Insurance coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, Newark, NJ. © 2026 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc., and its related entities, registered in many jurisdictions worldwide. 1081937-00004-00 14W50_EV_GI7_01

PBM PUGILISM

With the Big Three pharmacy benefit managers facing greater scrutiny, more independent players are jockeying for position Written By Bruce Shutan

David vs. Goliath battle continues to intensify across the pharmacy benefit management landscape as self-insured employers struggle with reining in their Rx spend. In one corner lie the so-called Big Three PBMs, which are vertically integrated with the nation’s largest health insurance companies and control about 80% of U.S. prescription drug claims. They include Express Scripts, which is owned by Cigna, CVS Caremark, which owns Aetna, and OptumRx, which is owned by the same parent company as UnitedHealthcare. At the other end of the ring are nearly 100 independent PBMs scrambling for the remaining slice of market share. Many claim their model is “transparent,” while a handful go out on a limb to describe their offering as “fiduciary.” But industry experts say semantics can be misleading. Self-insured group health plans appear to be giving the proverbial Davids of this industry a closer look. Consider, for example, that as many as 92% of 300 benefits decision-makers surveyed by the Penta Group for Evernorth believe a model that passes savings directly to members would improve transparency. Moreover, 90% said a PBM model without rebates would make it easier for employees to afford their medications and improve benefits satisfaction. 42

THE SELF-INSURER

HIGHER EXPECTATIONS

Whereas transparency was a differentiator nearly a decade ago in the PBM space, it’s now a minimum expectation, opines Jeff Malone, Co-Founder, President, and CEO of RxPreferred. He says the conversation has shifted to whether transparency is complete, auditable, and aligned, while the future will be backed by aligned incentives and real-time data. “Independent PBMs are gaining traction, especially among employers and health systems seeking greater flexibility and alignment,” Malone observes, noting how employers are now looking beyond size and perceived discounts. “They’re asking tougher questions about pricing, rebates, data ownership and conflicts created by vertical integration.”

Jeff Malone

A mass migration among small and midsize businesses from fully insured health plans to level-funding and self-funding has changed the rules of engagement with PBMs in recent years. “We’re seeing a big shift of market share increasing into that transparent PBM tranche in the market simply because of affordability,” says Jake Velie, Chairman and CEO of National Integrative Health. Another huge driver is the federal government ramping up regulatory scrutiny of PBM practices, with Acting Labor Secretary Keith Sonderling making the drafting of new PBM transparency regulations a top priority. Several states have also tried to block PBM ownership of pharmacies, concerned about conflicts of interest that may arise with such enormous scale. Arkansas is the only state that has enacted a law to do just that (in 2025), while proposals are pending in Tennessee and Arizona and under consideration in Indiana and Connecticut. Iowa also is considering aggressive PBM reforms. A CURTAIN OF COMPLEXITY

It’s easy to see why this is happening. The fact is that PBMs have operated behind a curtain of complexity for far too long, earning billions each year from spread pricing, rebate retention and opaque formulary steering in contracts with health plan sponsors, Velie argues. US-Rx Care President Renzo Luzzatti doesn’t see much clinical diligence or rigor across the transparent PBM industry in part because many of those owners haven’t ever done a prior authorization. “You got folks that were tired of pharmacy margins, and so they started a PBM,” he opines. Renzo Luzzatti

In light of these headwinds, his firm fields peer-to-peer calls with doctors on a regular basis, noting that the quickest way to resolve a disagreement is to simply pick up the phone and have a conversation with a clinician. In one case, he recalls how a doctor eventually admitted to prescribing a 40% higher growth hormone dosage for a patient that needed to be corrected. It saved the plan $33,000. “This stuff happens every day,” he reports. A pioneer in the independent PBM space, Luzzatti is aware of only a handful of organizations in the marketplace that – like his firm and Velie’s – actually describe themselves as a “fiduciary” PBM or pharmacy program. To do that, it means pledging that there will be no conflict of interest, such as accepting rebate money; they will look out solely for the best interest of the plan and its participants; and all utilization and financial information is in full view. SEPTEMBER 2026

“We cite the ERISA regs, and it means that we’re held to the same legal standard as our self-insured employer clients are as fiduciaries of their own plan,” he says. That contrasts with common language in PBM contracts that explicitly state that they’re not a fiduciary and not obligated to act in a fiduciary manner, he adds. Some will even allow for contracts to be canceled if a state requires PBMs to be a fiduciary. In addition, he says there are PBMs that call themselves transparent while also claiming they’re not obligated to act in a fiduciary manner. Most times, the inference is that they charge an admin fee and don’t do spread pricing. In that regard, Luzzatti explains that the word transparency is nebulous. “It’s not a legal term. You can’t take them to court over that. It’s whatever they say it is,” he says. A PBM may position certain formulary drugs in tier one and tier two to access greater rebates from the manufacturer, and hence usually pocket them, Velie observes. “You’re keeping certain brand drugs in a preferred tier when you should be putting a biologic there,” he says. The only industry players that actually meet the definition of a fiduciary PBM are those that are willing to do the reporting necessary for the fiduciary filing for the plan sponsor and hand them over to comply with their duties under the Affordable Care Act and Consolidated Appropriations Act of 2021, Velie notes. AN ABILITY TO ACCESS DATA

True price transparency lies in how PBMs get paid. “If we look at the PBMs that we like to work with, there’s no funny business in the contracts,” he explains. “They’re not trying to hide behind intellectual property contingencies in the contract. They’re showing you what the pricing is. Their fees are flat.” His company works with some PBMs that charge a per-script fee, while others charge an admin fee. Neither of those natural-flow models is easy to manipulate. He says there’s very little that a PBM can hide if the data is available. National Integrative Health deploys a multi-lever approach to achieve the lowest net cost on every claim for every member. It includes 340B pricing, biosimilars, 503B manufacturer direct contracting, variable copay programs, clinical interventions and clinical trial program access. Many of the transparent and fiduciary PBMs are operating on Big Three chassis that they’re white labeling, Velie says. What’s different is their business and contract practice, as well as a commitment to data transparency for the end client. Their relatively slow adoption can be traced to the snail’s pace of imposing regulatory changes on the healthcare industry when lobbyists still hold considerable sway over lawmakers, he adds.

Jake Velie

While jumbo employers can afford to stay with the Big Three, he notes that they’ve already been forcing them to improve practices because they have the leverage to do just that. Significant change is already afoot. For example, CVS Caremark recently agreed to allow clients to opt out of standard rebate-based payment designs and pass discounts directly through to consumers as part of a settlement with the Federal Trade Commission. Despite that move and any others that might follow, Velie believes the Big Three will still give careful thought to how they’re going to recover that lost revenue in other areas.

THE SELF-INSURER

Safe PASSAGE Companion Life can help you chart

BECAUSE IT ISN’T ALWAYS SMOOTH SAILING, YOUR STOP LOSS CLIENTS NEED PROTECTION.

We deliver best-in-class solutions that cover your clients and support you with experts in data analytics, underwriting, claim reimbursements, dedicated account management and CompanionCARESM. With CompanionCARE, you have access to experts in large case management and emerging therapies. Our stop loss contracts are backed with the strength reflected in our A+ AM Best company rating. In addition to specific and aggregate stop loss insurance, Companion Life offers an array of innovative products: Limited-Benefit Health Insurance Short Term Disability Insurance Short Term Medical Insurance Long Term Disability Insurance Group Medical Supplemental Insurance Vision Insurance Life Insurance Critical Illness Insurance Dental Insurance To learn more, visit CompanionLife.com or call us at 800-753-0404.

• • • • •

Companion Life Insurance Company 800-753-0404 | CompanionLife.com

• • • •

Companion Life has an AM Best Rating of A+ (Superior) as of Dec. 18, 2023. For the latest rating, access www.ambest.com. The rating represents an independent opinion from the leading provider of insurer ratings of a company’s financial strength and ability to meet its obligations to policyholders.

UNDERWRITING DECREMENTS

From a high-level strategic standpoint, the PBM serves as a linchpin to get underwriting consideration for plan design and execution on high-cost drugs, according to Velie. “We are constantly working with stop-loss carriers in underwriting and actuarial practices because we can predict our outcomes when we have the right plan design,” he reports. “So, when we give them our analysis during the underwriting process, it is guaranteed to work, and we are seeing normally up to 10% reductions in stop-loss renewals because we have the right formula and we cannot execute on the right formula without the right PBM partner.”

Scott Byrne

Blackwell Captive Solutions President Scott Byrne notes that as recently as three to five years ago, “most stop-loss carriers were not offering decrements for PBMs. It just wasn’t being factored into their manual rate whatsoever. They would factor in network and TPA, but PBMs surprisingly were left out of the mix.” Since that time, he says prescription drug costs swelled from roughly 20% to 25% of an employer’s annual health plan spend to more than 50%. Therefore, he believes this bigger piece of the pie deserves to be addressed and accounted for in a health plan’s pricing. Given all that’s at stake, pharmacy benefits are becoming a year-round risk management function instead of an annual renewal discussion, according to Malone. He says claim-level visibility allows employers to identify high-cost trends early, manage specialty drugs and GLP-1s proactively and coordinate pharmacy strategy with the broader health plan.

See What Your Benefits Strate s issin . Partner with PAI for the analytics, expertise, and flexibility to make every healthcare dollar count.

Get Started Today: PAISC.COM

THE SELF-INSURER

“WE’RE ALWAYS

FIGHTING AT WORK.”

If advocating for our members makes us Health Plan Rebels, so be it. From fighting for fair payments to cutting costs by up to 33% compared to traditional health plans, we give you a health plan you want, need and deserve. It’s time for a better plan — ours. Join us today.

claim-doc.com

Raquel Salamanca Balance Bill Specialist

One health system client of his was able to reduce pharmacy costs by 38% through a combination of transparent PBM administration, active utilization management and customized pharmacy strategies that leveraged its own pharmacy resources. EYEING EFFICACY

While the cost of prescription drugs is top of mind, so is the impact on clinical outcomes. Pressure is mounting on self-insured employers to determine whether drugs on their formulary are actually benefiting health plan members relative to other scripts in the face of rising medical and pharmacy costs, observes Katherine Shanahan, Director of Pharmacy Consulting for Merative. To put it another way, is there a meaningful enough return on investment? The use of GLP-1s for weight loss has spotlighted this concern. She says there’s such a high rebate percentage for these drugs that without price transparency, it’s difficult to determine whether there are downstream health improvements and savings from patients no longer experiencing flare-ups. While huge biometric improvements have been seen with GLP-1s, she notes that there’s still a lot of exploration with regard to stepping down a patient over time and realizing that longevity requires a different cost model. A RESTLESS MARKET

While some health plan participants are more comfortable having a household name on their ID card, Byrne believes smaller independent PBMs are achieving the most progress relative to the Big Three when it comes to transparency. He uses a construction analogy to describe the captive-PBM relationship, noting that the captive serves as the general contractor that builds a meaningful risk-management strategy and hires a PBM as one of several subcontractors. Choosing the right PBM is critical. “We want to bring bestin-class point solutions to our members because ultimately we need to be good stewards of their money,” he says.

Katherine Shanahan

As many as 30% of the employer population is out to bid now on a PBM in the course of a typical year, Luzzatti reports, noting that frustration is mounting upstream to jumbo employers and predicting that most self-insured clients will have made a change in three years. “Their concern from a legal standpoint is that they might be the next target like Johnson & Johnson, Wells Fargo and JPMorgan Chase. Nobody wants that,” he says. Velie predicts that there will be a meaningful shift in the market away from the Big Three given these highprofile lawsuits alleging that employers are overcharging for prescription drugs, and as a result, breaching their fiduciary responsibility under ERISA to act in the best interest of plan participants. “I think they can only survive so much bad publicity,” he says of the Big Three, “and now that these fiduciary and transparent PBMs are getting up to the point where they’re scalable, they can handle larger populations and serve their clients well. I think over the next five years, that segment of the PBM market will see more growth than they’ve seen in the last 15.”

THE SELF-INSURER

Historically, Shanahan points to constraints in the request-for-proposal process that have eliminated smaller or boutique PBMs from contention. However, she sees more midsize health plans having them at least fill out the remainder of the RFP and change some of the metrics they’re looking at even though they didn’t rank highest. Adds Malone: “Transparency tells an employer what happened. Alignment determines why it happened and whether the PBM had an incentive to deliver the best result.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for nearly 40 years.

The integrated TPA platform built for self-insured health plans SELF-INSURED EMPLOYERS

One connected system for care, claims, and compliance Most self-insured plans run claims, care, and reporting on separate systems. That disconnection creates errors, audit risk, and administrative burden your team absorbs every day.

Care Compass connects enrollment, claims adjudication, and compliance reporting in a single system — so your team stops reconciling across vendors and starts running a tighter operation.

PILLAR 1

PILLAR 2

PILLAR 3

Compliance built into daily work

One system, not a stack of vendors

A foundation that scales with you

Audit trails, regulatory reporting, and discrepancy detection embedded in every workflow — not a separate process at audit time.

Claims adjudication, provider payments, enrollment, and care management all run on the same platform. No duplicate entry. No data gaps.

Add programs, grow census, or expand services without replatforming. 30 years of complex care experience behind it.

See it in Action

ppi.com

30+

13K+

YEARS MANAGED CARE

PROVIDERS SUPPORTED

#1 LARGEST U.S. PACE ORG IS A CLIENT

SEPTEMBER 2026

DOL PROPOSES NEW ELECTRONIC DISCLOSURE SAFE HARBOR FOR GROUP HEALTH PLANS

Written By Alston & Bird Health Benefits Practice

he Department of Labor has proposed a significant expansion of ERISA electronic disclosure rules by creating a new electronic-delivery safe harbor for group health plans. The proposal largely extends to health plans the notice-and-access framework that has applied to pension plans since 2020, allowing plan administrators to furnish most ERISA-required disclosures electronically through a website accompanied by a Notice of Internet Availability. If finalized, the rule would substantially modernize health plan disclosure practices, reduce reliance on paper mailings, and potentially generate hundreds of millions of dollars in annual administrative savings, while preserving participants’ rights to request paper copies and opt out of electronic delivery entirely. OVERVIEW OF THE PROPOSED RULE

The proposal would add a new ERISA electronic disclosure safe harbor specifically for group health plans under proposed 29 C.F.R. § 2520.104b-32. Under the new framework, a health plan administrator could satisfy ERISA’s disclosure obligations by: • • • • 50

Posting required disclosures to a website or other electronic repository; Sending participants a Notice of Internet Availability informing them that the document is available online; Providing free paper copies of any covered disclosure upon request; and Allowing participants to opt out of electronic delivery and receive paper disclosures. THE SELF-INSURER

The proposal is intended to supplement—not replace—the current 2002 “wired at work” electronic disclosure safe harbor, which required electronic access at the worksite. Plan administrators could continue using the existing rules or continue furnishing paper disclosures if they prefer. The proposal would allow insurers that agree to fulfill plan disclosure obligations to use the new safe harbor. The DOL estimates the proposal could save approximately $402 million annually by reducing printing and mailing costs associated with ERISA health plan disclosures. APPLICATION OF THE SAFE HARBOR

The safe harbor applies to ERISA-covered group health plan documents or information that the administrator is required to furnish to participants and beneficiaries pursuant to Title I of ERISA, as well as documents that must be furnished upon request. Examples of Group Health Plans Subject to Arrangements Typically Not Subject to New Rule New Rule Group health coverage, dental coverage, vision coverage, EAP coverage, HRAs, ICHRAs, most wellness programs, health FSAs,

HSAs, dependent child/day care arrangements, life insurance, disability coverage, parking and transit programs

Examples of Group Health Plan Communications Covered by New Rule

Examples of “On Request” Communications Covered by New Rule

SPDs, SMMs, SBCs, CHIP Notice, MHPAEA NQTL CAA

Any ERISA document required to be furnished upon request, including but not limited to COBRA Communications and Notices, Claims and Appeals Communications, etc. [Note: That in order to utilize the e-delivery mode a valid work email must exist (for the employee) or be provided (e.g., for spouse/dependents).]

To rely on the safe harbor, the group health plan administrator must receive an email address or number to communicate with a covered individual. Prior to relying on the safe harbor, the administrator is required to furnish an initial notification to each individual of the intent to communicate electronically. While this notice must generally be in writing, a plan administrator may rely on the 2002 safe harbor (allowing electronic communications to certain “wired at work” employees) to furnish this initial notice electronically. The initial notification should include the following information: • • • • •

a notification that covered documents will be furnished electronically to an electronic address; identification of the electronic address that will be used for the individual; any instructions necessary to access the covered documents; a cautionary statement that the covered document is not required to be available on the website for more than one year or, if later, after it is superseded by a subsequent version of the covered document; a statement of the right to request and obtain a paper version of a covered document, free of charge, and an explanation of how to exercise this right; and a statement of the right, free of charge, to opt out of electronic delivery and receive only paper versions of covered documents, and an explanation of how to exercise this right. SEPTEMBER 2026

HOW THE PROPOSAL COMPARES TO THE CURRENT 2002 E-DISCLOSURE RULE

Current Rule: Limited Electronic Delivery Under the current 2002 safe harbor, electronic delivery generally is permitted only for: 1. 2.

Employees who are “wired at work”—that is, employees who use electronic systems as an integral part of their job and have effective work-related access to disclosures; or Individuals who affirmatively consent to electronic disclosure and satisfy detailed consent procedures.

The affirmative consent process can be administratively burdensome. It requires detailed disclosures regarding hardware and software requirements, withdrawal rights, and consent procedures, and may require renewed consent when technological requirements change. PROPOSED RULE: DEFAULT ELECTRONIC DELIVERY

The proposed rule would largely eliminate the need to determine whether participants are “wired at work” or to obtain affirmative consent. Instead, electronic delivery would generally be available whenever the participant or beneficiary has provided an electronic address, or has been assigned one by an employer. This represents the proposal’s most significant policy change: moving from an opt-in model to a default electronic delivery model, while retaining participant protections through paper-copy and opt-out rights.

EXPERIENCE YOU CAN COUNT ON. SOLUTIONS YOU CAN TRUST. In a market where many stop loss providers compete on price alone, StarLine delivers something more valuable: access, expertise, and solutions. Our underwriting team works directly with producers and their clients to understand each risk, develop creative structures, and deliver customized stop loss solutions that fit your client’s needs.

starlinegroup.com | (508) 495-0882

CREATIVE UNDERWRITING. DIRECT ACCESS. REAL SOLUTIONS.

THE SELF-INSURER

SIMILARITIES TO THE 2020 PENSION PLAN SAFE HARBOR

The proposal is intentionally modeled on the pension plan electronic disclosure rule adopted in 2020, which follows a notice-and-access framework. Under this framework, plan administrators must notify plan participants and beneficiaries about the online disclosures, provide information on how to access the disclosures, and inform participants and beneficiaries of their rights to request paper copies or opt out completely. Like the 2020 pension plan safe harbor, the proposed rule would: • • • • • • •

Use a notice-and-access framework; Require a NOIA whenever documents are posted; Require website accessibility, readability, and searchability standards; Require confidentiality safeguards; Permit annual combined NOIAs; Require procedures to address invalid electronic addresses; and Preserve participant rights to paper copies and global opt-outs.

In many respects, the proposed rule simply extends the operational structure of the pension plan safe harbor to group health plans. KEY DIFFERENCES FROM THE 2020 PENSION PLAN RULE

Although the proposal closely tracks the pension plan framework, several notable differences reflect the unique privacy concerns associated with health-plan information.

SEPTEMBER 2026

1. No Direct Email Delivery Option Perhaps the most important difference is that the proposal does not permit the alternative direct-email delivery method available under the pension plan safe harbor. Under the pension rule, administrators may furnish covered documents directly by email. The DOL declined to extend that feature to health plans because many health-plan disclosures may contain sensitive health information or protected health information. The Department expressed concern that emailing such information—particularly to employerissued email accounts—could create privacy risks. 2. Broader Definition of Covered Documents The proposal is broader than the pension safe harbor in one important respect. The pension rule excludes documents that must be furnished only upon request. By contrast, the proposed health-plan rule would allow electronic delivery even for documents that must be furnished solely upon request, such as certain plan documents requested under ERISA § 104(b)(4). The DOL explains that excluding the email delivery option justified providing additional flexibility elsewhere in the rule. 3. Adult Dependent Children as Covered Individuals The proposal expressly allows dependent children aged 18 or older who provide their own electronic address to receive disclosures directly. This provision appears tailored to health-plan administration and has no direct analog in the pension context. 4. Modified Initial Notice Requirement Another notable difference involves the transition rules. Under the pension safe harbor, existing participants generally received the initial transition notice on paper. The health-plan proposal would allow administrators to send the initial transition notice electronically to individuals already receiving disclosures electronically under the 2002 safe harbor (i.e., employees who qualify as “wired at work” or who opted into electronic disclosure). PRACTICAL IMPLICATIONS FOR HEALTH PLAN SPONSORS

For employers and plan administrators, the proposal would significantly simplify electronic disclosure compliance. The need to track who qualifies as “wired at work,” obtain affirmative consent from nonworkforce individuals, and maintain consent documentation would largely disappear. Participants could instead be treated as electronically connected by virtue of providing an email address or mobile number. At the same time, plan sponsors would need to implement new operational requirements, including website maintenance standards, NOIA procedures, monitoring for invalid electronic addresses, and optout processing systems. They would also need to continue complying with HIPAA privacy and security requirements independent of the new safe harbor. For example, HIPAA has its own protocol for the delivery of HIPAA-required notices. TAKEAWAY

The proposal represents the most significant change to ERISA health-plan disclosure rules in more than two decades. By extending a modified version of the 2020 pension-plan notice-and-access model to group health plans, the DOL seeks to replace the current consent-based approach with a default electronicdelivery framework that better reflects contemporary communication practices. At the same time, the 54

THE SELF-INSURER

COLD Rx MEDS

COST CONTAINMENT

TPAs & PBMs

BROKERS

Why is specialty drug spend still your #1 uncontrolled cost? Your GLP-1 spend has a fix. It’s defensible. It starts on day one. THE ONLY INTERNATIONAL SOURCING PROGRAM YOUR CFO CAN DEFEND AT THE BOARD LEVEL.

30–70% IMMEDIATE SAVINGS · FROM THE FIRST FILL · NOT A REBATE

MANITOBA IPS LICENSE The only Canadian province with a dedicated IPS licensing framework for international Rx fulfillment. Every order traced to a licensed pharmacist. Audit-ready.

BRAND-NAME ONLY No compounding. No grey market. Every drug DIN-matched to U.S. NDC — therapeutic equivalence confirmed on every fill.

COLD-CHAIN VALIDATED Temperature-controlled 2–8°C end-to-end, pharmacy to member door. 19-field dispensing records with every shipment.

$0 WORKFLOW CHANGE Overlays your existing PBM or TPA program seamlessly. Voluntary member opt-in. Savings begin on the first claim cycle.

BUILT FOR:

Third-Party Administrators

Self-Insured Employers

Cost-Containment Programs

Pharmacy Benefit Managers

Benefits Brokers & Consultants

Get a Free Drug-by-Drug Savings Analysis — 48 Hours. Confidential · No Commitment · coldrxmeds.com

ColdRxMeds · Manitoba IPS License · Brand-Name Only · Cold-Chain Validated · coldrxmeds.com

proposal preserves participant protections through free paper copies, universal opt-out rights, website accessibility standards, and HIPAA-sensitive privacy protections. If finalized substantially as proposed, plan sponsors will gain a more streamlined pathway to electronic disclosure while participants retain meaningful control over how they receive important health-plan information.

Attorneys John Hickman, Ashley Gillihan, Amy Heppner, Laurie Kirkwood, and Michelle Jackson provide the answers in this column. John is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley is a partner in the practice, and Amy, Laurie, and Michelle are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to John at john. hickman@alston.com.

THE SELF-INSURER

FEDERAL SURPRISE BILLING FINAL IDR OPERATIONS RULE – THE SIIA ANALYSIS

Helpful Changes, But Fundamental Problems Remain By Anthony Murrello

early five years after the Surprise Medical Billing Rules took effect, the Federal Independent Dispute Resolution (IDR) Process continues to create headaches and significant operational challenges. Rather than functioning as Congress intended, the Process has been exploited by bad actors, particularly private equity-backed provider groups and IDR dispute middlemen, who have fueled fraud, waste, and abuse within the system. The result is a Process that is driving up healthcare costs for employers and consumers alike, while moving further away from the original purpose of protecting patients from surprise medical bills. SIIA and our coalition partners have consistently communicated these concerns to members of Congress and the Federal Departments, but fundamental reforms to the Process remain elusive.

SEPTEMBER 2026

Recent data indicates the magnitude of the problem. According to the non-partisan Congressional Budget Office (CBO), the volume of IDR disputes has far exceeded original projections, with arbitration awards often substantially higher than expected. The CBO also found that a relatively small number of organizations account for a disproportionate share of all disputes; for example, just five organizations generated nearly 60 percent of all IDR filings. Recent reports have also shown IDR awards reaching three to nine times typical in-network reimbursement rates, with some specialties receiving awards many multiples higher than negotiated commercial rates. CMS data further indicates that providers received nearly $15 billion through the Federal IDR Process during 2025 alone, a nearly 275% increase over the previous year. This abusive behavior has transformed the IDR Process into a high-volume business model, and a profitable one for certain providers, including providers backed by private-equity groups. As discussions surrounding broader structural reforms to the Surprise Billing Rules continue, the Federal Departments (i.e., the Departments of Health and Human Services, Labor, and Treasury) recently finalized regulations that should help improve the operation and administration of the Federal IDR Process. While these regulatory changes largely address procedural inefficiencies on the margins – rather than the underlying issues and perverse incentive structures that continue to drive excessive dispute filings and inflated arbitration awards (as discussed above) – these final regulations represent an important step toward making the IDR Process more transparent and administratively efficient. WHAT DOES THE FINAL IDR OPERATIONS RULE DO?

The recently released final regulation includes several changes intended to streamline dispute resolution and reduce unnecessary administrative burdens. One of the more significant changes is the creation of standardized communication requirements between self-insured plans and insurance carriers (i.e., healthcare payers) and out-of-network medical providers. Here, payers must now include specified Claim Adjustment Reason Codes (CARCs) and standardized Remittance Advice Remark Codes (RARCs) when issuing remittance advice for applicable out-of-network claims. This information (which explains why a claim was paid differently than it was billed (through the CARCs) and identifies any adjustment to the billed amounts (through the RARCs)) is intended to tell providers whether the claim is subject to the Federal Surprise Billing rules or not. As such, the Departments believe that this change will reduce the number of ineligible disputes submitted to the Federal IDR Portal. On the heels of the release of the final rule, the Federal Departments subsequently issued implementing guidance enumerating the required RARCs, explaining when each code must be used, and providing technical instructions for both electronic and paper remittance advice. While plans may continue using the CARCs they deem most appropriate for claim adjustments, plans must include one of the required RARCs for applicable items and services. These requirements take effect August 3, 2026. This guidance (which can be found on CMS’s website) also explains that if the failure to provide this required information prevents a medical provider from timely initiating the IDR process, the provider may request an extension to initiate a dispute.

THE SELF-INSURER

Additional changes in the final rule include: ●

Requiring both parties to initiate and manage the Open Negotiation Process through the Federal IDR Portal, creating a documented timeline, and reducing disputes over whether negotiations properly occurred. This also helps both payers and providers (and the Federal government) track the 30-business-day Open Negotiation timeline, instead of payers being surprised when a provider skips Open Negotiation and goes straight to Federal IDR.

●

Expanding batching and bundling rules to allow certain related claims to be resolved within a single dispute while establishing reasonable limits on the number of line items included. The final rule also allows disputes to be bundled by a single CPT, DRG, or HCPCS code.

●

Extending eligibility determination timelines to provide Certified IDR Entities (CIDREs) additional time to evaluate disputes and obtain necessary information from the parties. CIDREs must now determine whether a claim is eligible (or ineligible) for the Federal IDR Process within 5 business days of the CIDRE being selected to review the dispute.

●

Reducing the administrative fee for initiating an IDR dispute from $115 to $15 per party. If the initiating party fails to pay the administrative fee within 2 business days of the selection of the CIDRE, the dispute will be closed, and neither party will be responsible for paying the administrative fee.

●

Creating a new Federal IDR Registry requiring payers to register with the Departments and obtain a Federal IDR registration number, making it easier for providers to identify the appropriate payer contact when disputes arise. For self-insured plans that hire a TPA or other plan service provider to help the plan navigate the Federal IDR Process and/or submit offers on behalf of the plan, information for the TPA or service provider must be included in the registration to ensure that the provider knows what plans the TPA/service provider represents.

Keep Your PBM. Layer in More Savings. Aphora Health works alongside your existing pharmacy benefit to help lower costs across specialty, brand, and generic medications, without waiting for renewal. $0 copays on covered prescriptions Human Care Navigation No PBM change required SCAN HERE TO GET A NO-COST SAVINGS ANALYSIS See what Aphora could save your plan at AphoraHealth.com No cost. No commitment. Just the numbers.

SEPTEMBER 2026

FEDERAL IDR GATEWAY

In addition to the operational and administrative changes to the Federal IDR Process set forth in the final rule, CMS is also moving forward with the implementation of the Federal IDR Gateway Platform, a centralized technology platform designed to improve the efficiency and administration of the IDR process. More specifically, the IDR Gateway Platform – which is effectively an upgrade of the existing Federal IDR Portal – is intended to modernize the existing IDR infrastructure by streamlining case submissions, improving communication between disputing parties, enhancing data collection, and reducing administrative burdens associated with managing disputes. The IDR Gateway Platform is expected to be introduced by late 2026. LOOKING AHEAD

The final IDR Operations rule, the release of implementing guidance for the CARCs and RARCs, and the upcoming implementation of the Federal IDR Gateway platform represent progress toward improving the day-to-day administration of the Federal IDR Process. Standardized remittance requirements, clearer operational procedures, and enhanced communication between payers and providers should reduce avoidable disputes and improve administrative efficiency. Additionally, these administrative changes should improve the amount and quality of data the Federal Departments can collect on the IDR Process. As implementation of the final rule continues, SIIA and our coalition partners will monitor how these operational changes are impacting self-insured plans, while continuing to advocate and fight for broader reforms that preserve the original intent of the Surprise Billing Rules, which is: Protecting patients from surprise medical bills without creating incentives that increase healthcare costs for employer-sponsored health plans and the individuals they cover.

Anthony Murrello serves as government relations manager for SIIA. He can be reached at amurrello@siia.org.

THE SELF-INSURER

Complex Healthcare Doesn’t Have to Be Complicated Mayo Clinic Complex Care Program

55%

of patients experience a change in diagnosis

Your clients are navigating rising healthcare costs and clinical uncertainty. The Mayo Clinic Complex Care Program is a customizable center of excellence solution for high-risk, high-cost members. We work with employers, brokers, consultants, TPAs, and navigation services to deliver the right diagnosis and right treatment plan. All without added fees. Let’s collaborate to reduce spend and elevate care. Learn more: mayoclinic.org/complex-care-program © 2025 Mayo Clinic

82% see a change in treatment plan

NEWS

NEWS FROM SIIA MEMBERS SEPTEMBER 2026 SIIA boasts a very active and dynamic membership. Here are some of the latest developments from member companies and individuals powering the self-insurance industry. Matthew Cooper Joins Crum & Forster’s Stop-Loss Team Crum & Forster’s (C&F) Accident & Health (A&H) Division announced that Matthew Cooper has joined the C&F Stop-Loss (CFSL) Sales team within the Medical Business Unit (MBU) as Vice President. In this role, Cooper will lead the CFSL Sales team and partner closely with CFSL and MBU leadership to drive growth across all U.S regions, with a focus on new business sales, renewal performance, producer relationships, and alignment across Sales, Underwriting, Claims, and other key functional teams. 62

THE SELF-INSURER

NEWS “Matt brings outstanding stop-loss insurance market knowledge, deep producer relationships, and a proven record of building high-performing sales organizations,” said David Webb, Senior Vice President, C&F Stop-loss at Crum & Forster. “His leadership experience, strategic mindset, and collaborative approach make him an excellent addition to our team as we continue to expand our market presence, strengthen our producer partnerships, and drive profitable growth across the business.” Cooper brings 30 years of sales and sales leadership experience across the stop-loss insurance market. He joins C&F from Reinsurance Group of America, where he served as Vice President of Business Development – StopMatthew Cooper loss and led the national go-to-market strategy for Employer Stop-loss. C&F Stop-loss (CFSL) Prior to that, he held leadership and sales roles at Berkley Accident and Health and Arizona Benefit Plans. Throughout his career, Cooper has built expertise in sales leadership, market expansion, producer strategy, and cross-functional partnerships. “I’m excited to join Crum & Forster and the Accident & Health Division at such an important time within the business,” said Cooper. “C&F has built a strong reputation in the market through its underwriting expertise, service commitment, and collaborative culture. I look forward to working with the CFSL insurance team and our partners across the Medical Business Unit to help deliver positive outcomes and strong results nationwide.”

SEPTEMBER 2026

NEWS Caribou and ELMCRx Announce New Brand Launch Caribou Systems, Inc. has unveiled a new brand identity, marking a pivotal evolution for the firm and reinforcing its commitment to delivering independent oversight across pharmacy benefit management. Building on more than 25 years of industry leadership, Caribou is sharpening its strategic focus on pharmacy claims auditing, payment integrity, and fiduciary solutions, beginning in the third quarter of this year. Concurrent with this new brand identity, ELMCRx, which acquired Caribou in 2025, is also rebranding under the Caribou name, pivoting away from clinical services to focus exclusively on pharmacy claims auditing, claims monitoring, and fiduciary oversight - the areas of greatest need amid mounting legislative, regulatory, and financial pressure across the PBM industry. "This rebrand reflects both who we are and where we are going," said Richard Fleder, Caribou's Chief Executive Officer. "Stepping away from our clinical services was a deliberate choice, made because the industry's greatest need right now is independent auditing, claims monitoring, and fiduciary oversight. Caribou's singular focus beginning in Q3 on these disciplines ensures we remain on the frontline of helping the self-funded market navigate increasing complexity with confidence and clarity."

Amalgamated Life Insurance Company Medical Stop Loss Insurance— The Essential, Excess Insurance As a direct writer of Stop Loss Insurance, we have the Expertise, Resources and Contract Flexibility to meet your Organization’s Stop Loss needs. Amalgamated Life offers:

• Specialty Rx Savings Programs and Discounts

• Excellent Claims Management Performance

• “A” (Excellent) Rating from A.M. Best Company for 48 Consecutive Years

• Specific and Aggregate Stop Loss Options

• Licensed in all 50 States and the District of Columbia

• Participating, Rate Cap and NNL Contract Terms Available

• Flexible Contract Terms

VOLU NTA RY SOLUTION S—KEEPIN G PACE WITH TOD AY’S NEEDS

• Accident

• AD&D

• Critical Illness

• Dental

• Disability

• Hearing

• ID Theft

• Legal

• Portable Term Life

Amalgamated Life Insurance Company 333 Westchester Avenue, White Plains, NY 10604 914.367.5000 • 866.975.4089

• Whole Life Insurance

For product information, contact: marketing@amalgamatedbenefits.com

www.amalgamatedbenefits.com

Group • Stop Loss • Voluntary

Policy Form ALSLP-2020* *Features & form numbers may vary by state.

A M A L G A M AT E D F A M I LY O F C O M PA N I E S

THE SELF-INSURER

| Amalgamated Life | Amalgamated Employee Benefits Administrators | Amalgamated Agency | AliGraphics

A M

BES S ST T

NEWS "Caribou has long been recognized as the preeminent independent PBM auditing firm in the country, and this next chapter is about building on that reputation," said Amy Gasbarro, President of Caribou. "With the added focus and resources behind our team today, we're positioned to deliver even greater rigor and value to the brokers, consultants, and plan sponsors who depend on us." New Brand Identity for Gradiant AI Gradient AI, a prominent enterprise software provider of artificial intelligence solutions for the insurance industry, has debuted a refreshed brand identity reflecting the company’s ongoing evolution. Given its rapid emergence as a premier architect of AI-enabled decision intelligence platforms, the top-down makeover exemplifies the company’s expansion from its startup roots to a deeply trusted partner for carriers, third-party administrators (TPAs), brokers, and self-insured employers navigating complex risk decisions in the group health, property & casualty, and workers’ compensation segments. According to a company statement, the brand refresh represents a strategic inflection point: since its founding in 2018, the company has dramatically expanded its customer base, data assets, and platform capabilities, while experiencing double-digit year-over-year growth and securing $56 million in Series C funding. In doing so, Gradient AI accrued one of the insurance industry’s largest data lakes, a trove spanning tens of millions of policies and claims. This rich well of intelligence helps Gradient AI solutions integrate with existing systems and workflows in a fashion that is purpose-built for insurance rather than adapted from general AI products. "Over the past several years, we've built powerful technology, earned deep trust with our customers, and helped the insurance industry make better, higher-stakes decisions with AI,” said Stan Smith, CEO of Gradient AI. “As our impact has grown, it's become clear that our brand must evolve to reflect who we are today. We're not just refreshing our look; we're showing up as the platform partner that integrates across workflows, addresses high-complexity risk, and delivers measurable outcomes our customers can stand behind.”

Gene Pompili to Lead Stop-Loss Division at Amynta Amynta Risk Solutions announced the appointment of Gene Pompili as president of its accident and health and medical stop-loss division. Pompili joins from ClearPoint Health, where the role was chief strategy officer. Responsibilities there covered enterprise strategy and long-term business planning, growth initiatives across captive and healthcare financing programs, and the development of the firm's Stop-Loss Center of Excellence.

Gene Pompili Amynta Risk Solutions

SEPTEMBER 2026

NEWS Pompili was previously vice president and group benefits risk leader at Oswald Companies, leading the firm's group benefits captives practice and its consulting team. The role involved designing and managing captive and risk-sharing programs and advising employers on self-funded healthcare strategies and cost-containment approaches. Marpai Announces Latest Investment Marpai, Inc., a leader in innovative healthcare technology, Third-Party Administration ("TPA"), and Pharmacy Benefit Management ("PBM") services, today announced that it entered into securities purchase agreements with accredited investors in a private placement of newly designated convertible preferred stock. The offering was led by Mitchell Companies.

THE SELF-INSURER

vi ces

acy

r Se

Your health plan can do better. We promise.

T PA

Employers navigate enough challenges without the strain of large, annual healthcare increases. We help employers take back control of their health plan costs with integrated solutions designed to meet today’s demands.

cal i d

Alternative health plan solutions built for today

M e

The investment is intended to accelerate Marpai's growth trajectory, strengthen its technology-enabled healthcare services platform, advance the Company's mission of delivering smarter, more efficient healthcare administration solutions for employers, members, brokers, and healthcare partners, and strengthen Marpai's financial position.

p Sto

imagine360.com

Inspiring Confidence Accelerating Progress

ANNUAL MARKET REPORT Tokio Marine – A&H Group A member of the Tokio Marine HCC Group of Companies TMHCC1310 - 05/2026

HCC Life Insurance Company operating as Tokio Marine HCC – A&H Group For producer use only. Not for public distribution.

Scan to Read

HCC Life Insurance Company operating as Tokio Marine HCC – A&H Group

Tokio Marine HCC – A&H Group is pleased to present our 2026 Annual Market Report. We hope you find this information useful and encourage you to scan the QR code to view the full report. If you have any questions, please contact your sales representative or visit tmhcc.com/AHGroup to learn more about our products, services, and solutions.

Tokio Marine HCC – A&H Group A member of the Tokio Marine HCC Group of Companies TMHCC-1329- 09/2026

Visit us online at tmhcc.com/AHGroup #TMHCC_AHGroup For producer use only. Not for public distribution

NEWS "The investment is a massive catalyst for Marpai," said Damien Lamendola, CEO of Marpai. "This $12 million investment ensures we are well capitalized to execute our strategic vision, accelerate our technology roadmap, and scale our operations. Mitchell Companies shares our absolute commitment to transforming healthcare administration, and their financial backing provides both the capital and strategic alignment we need to execute the incredible market opportunities ahead and deliver unmatched value to our clients." "We are thrilled to back Marpai as they embark on this exciting next phase of growth," said Steve Mitchell, Chairman of Mitchell Companies. "Our team has immense confidence in Damien Lamendola and the entire Marpai leadership group. We believe that Damien possesses the exact combination of visionary leadership, deep industry knowledge, and operational focus required to take the Company to new heights. We believe that Marpai is uniquely positioned to build a highly differentiated, world-class healthcare services platform that creates lasting value for employers and partners alike."

Buyers Look Under the Hood What Would Your Tech Stack Reveal? IPS helps modernize claims administration with a secure, Salesforce-backed platform built for faster implementation and long-term value.

Salesforce Cloud Platform

60-180 day Implementation

Automated Claims Adjudication

Built-In Compliance Workflows

Tune Up the Tech Behind Your Growth. Book Your Demo Today. integratedpayorsolutions.com

THE SELF-INSURER

NEWS

Nova Recognized by the Validation Institute Nova Healthcare Administrators, Inc. has been recognized by the Validation Institute as a Validated ThirdParty Administrator, a newly established designation that evaluates transparency and business practices within the TPA market. This recognition reflects Nova’s commitment to transparency, accountability, and alignment with plan sponsor interests — key priorities for employers seeking greater control over healthcare costs and outcomes. The designation is part of a new initiative from the Validation Institute designed to bring increased visibility to how TPAs operate, particularly in areas such as claims administration, vendor relationships, and fee structures. As part of the process, organizations are required to provide detailed, transparent responses regarding their business practices and revenue models. Achieving the validation affirms that Nova demonstrates a consistent focus on: •

Full transparency in administrative fees and third-party services

•

No undisclosed markups or referral fees from vendors or providers

•

Flexibility for plan sponsors to engage third-party vendors and auditors

•

Administrative processes that strictly follow plan documents and sponsor direction SEPTEMBER 2026

NEWS As employer expectations continue to evolve, there is growing demand for greater clarity around how healthcare dollars are spent and how administrative partners operate. “This new designation helps bring much-needed transparency to the TPA space,” said James Walleshauser, president, Nova. “We’re proud to be among the organizations helping to set that standard. This recognition reinforces Nova’s core values and long-standing commitment to helping employers get more from their health plans: through transparency, education, and a personalized, hands-on approach that supports better decisions and better outcomes for the people they serve.”

Elizabeth Vire Auxiant

Auxiant Expands Sales Team With Elizabeth Vire Appointment Auxiant, a leading independent TPA, announced that Elizabeth Vire has joined the company as a National Sales Executive. Vire brings more than 15 years of experience helping employers and consultants implement innovative self-funded health benefit strategies that improve outcomes while lowering healthcare costs.

Backed by disciplined underwriting, claims intelligence, and flexible stop-loss solutions, we deliver the consistency and adaptability needed to navigate uncertainty, manage risk effectively, and stay positioned for long-term success.

Don't just react to a tightening market.

sales@umexperts.com

Stay ahead of it with UME.

UMExperts.com

THE SELF-INSURER

Interstellar SIIA National Conference Party | October 13, 2026 JW Marriott Desert Ridge | Ballroom Lawn | 7:30p - 10p