Case Study · 2017–2025
Nine years of actual plan data.
No projections. No modeled savings. Just receipts — the actual stop-loss contracts, aggregate reports, paid claims, admin costs and enrollment records of a German-owned U.S. employer across nine consecutive years.
One client. One approach. Brokers removed, networks removed, middlemen removed — and someone paying attention to the plan. Medical and pharmacy combined.
$6.49M
Actual all-in cost (9 years)
$10.38M
Weighted national benchmark
$3.89M
Below benchmark
37.4%
Below benchmark overall
The record
Every year, every dollar — compared to the national benchmark.
Figures are actuals drawn from the plan's own records: stop-loss contracts, aggregate claims reports, administrative cost schedules and enrollment files. The benchmark is a weighted national average for comparable employer plans. Medical and pharmacy are combined.
| Metric | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 | 2025 | 9-Yr Total |
|---|---|---|---|---|---|---|---|---|---|---|
| Avg single employees | 37 | 42 | 47 | 38 | 40 | 42 | 44 | 44 | 50 | 384 |
| Avg family employees | 36 | 50 | 38 | 40 | 39 | 37 | 35 | 32 | 26 | 333 |
| Total covered employees | 73 | 92 | 85 | 78 | 79 | 79 | 79 | 76 | 76 | 717 |
| Actual claims paid | $588K | $554K | $677K | $346K | $423K | $428K | $456K | $397K | $310K | $4.18M |
| Actual all-in plan cost | $765K | $836K | $981K | $594K | $705K | $672K | $731K | $668K | $541K | $6.49M |
| Cost per employee | $10,479 | $9,088 | $11,540 | $7,620 | $8,921 | $8,512 | $9,256 | $8,790 | $7,116 | $9,057 |
| Weighted national benchmark | $923K | $1.27M | $1.12M | $1.14M | $1.17M | $1.16M | $1.21M | $1.21M | $1.17M | $10.38M |
| Difference vs. benchmark | −$158K | −$434K | −$139K | −$543K | −$471K | −$491K | −$479K | −$544K | −$627K | −$3.88M |
| National avg deductible | $1,505 | $1,573 | $1,655 | $1,644 | $1,669 | $1,763 | $1,735 | $1,787 | $1,886 | $1,691 |
| Client deductible | $500 | $500 | $500 | $500 | $500 | $500 | $500 | $500 | $500 | $500 |
2025 alone: $540,853 actual all-in cost vs. $1,168,068 benchmark — $627,215 below benchmark, while the client deductible stayed at $500. Source: actual historical plan records, 2017–2025.
Source: KFF Employer Health Benefits Surveys, 2017–2025. Client figures derived from actual stop-loss contracts, aggregate reports, claims records, administrative fee schedules and enrollment records.
The deductible
$500. Every year.
While the national average deductible climbed from $1,505 in 2017 to $1,886 in 2025, this client's employees never paid more than $500 out of pocket before the plan began paying.
Lower cost to the employer and lower cost to the employee — at the same time, in the same plan, for nine consecutive years. That is not what the U.S. healthcare market expects. It is what happens when someone reads the contracts, questions the pricing, and refuses to let intermediaries set the terms.
What happened
The intermediaries were removed.
The broker was let go. The network was removed. The middlemen who earn from the plan without accountability to it were taken out of the chain. What remained was a direct relationship between the employer, the claims administrator and the providers — read carefully, every year, by someone whose only interest was the employer's.
The numbers speak for themselves. Over nine years, the plan cost $6.49M against a weighted national benchmark of $10.38M. That is $3.89M — 37.4% — that stayed with the company instead of flowing to carriers, intermediaries and inflated provider charges. In 2025, the final year on record, the gap was the widest it had ever been.
This is not a projection of what might happen. It is a record of what did happen — nine years of it, documented in the plan's own files.
Second case · Preliminary audit
Three claims and one pharmacy program. $117,157 in question.
A separate, unrelated employer plan. Not a full audit — a preliminary review of three surgical and emergency encounters plus six high-cost specialty pharmacy fills. Client, vendor, provider and claim identifiers have been removed; the figures are unchanged.
3
Medical claims reviewed
6
Specialty pharmacy fills reviewed
$156,809
Total plan outlay in audited scope
$117,157
Potential excess expenditure identified
What the claims showed
A flat 10% discount, applied to everything.
Across three independent outpatient surgical and emergency encounters, the plan paid 90% of billed charges on virtually every line — complex surgery, routine laboratory panels, facility supplies, and repeated intraoperative drug and administration charges alike. There was no apparent application of bundling, packaging, duplicate-line or cross-code adjudication edits of the kind standard reimbursement methodology would normally apply.
In one encounter, potential overpayment reached roughly 78% of billed charges. One imaging study alone was paid at $2,926 against an audited value of $650. A single therapeutic injection was billed and paid twice.
| Audited item | Billed | Plan paid | Audited value | In question |
|---|---|---|---|---|
| Outpatient surgical encounter (1) | $45,516 | $40,965 | $12,901 | $28,064 |
| Outpatient surgical encounter (2) | $25,516 | $22,965 | $7,143 | $15,822 |
| Emergency & observation encounter | — | — | — | $10,837 |
| Specialty pharmacy — six fills | $111,125 | $40,947 | $17,959 | $22,988 |
| Vendor savings-based fees | — | $39,446 | — | $39,446 |
| Total in question | — | $156,809 | $39,653 | $117,157 |
Figures as audited. The pharmacy row reflects six fills sourced through an "alternative sourcing" specialty programme. Identifying details of the employer, the administrator, the vendors and the providers have been removed.
What the pharmacy program showed
Savings were reported. Fees were charged. The market price was lower.
Six specialty fills were sourced outside the ordinary pharmacy benefit. The programme reported "group savings" by comparing its own reference price against its sourcing cost, and charged the plan $39,446 in savings-based compensation on that basis.
The plan paid $40,947 in sourcing costs for those six fills. The audited local-market value of the same medications was $17,959. In three fills of one generic antiparasitic medication, the plan paid over $7,200 each time for a drug available locally for under $200.
Three claims and six fills is not a full audit. It is the sample that made a full audit unavoidable.
The principle
The U.S. healthcare system does not reward attention by default. It rewards volume, layers and deference. When those are removed — and someone pays attention — the plan costs less, the employees pay less, and the record proves it.