Category: Latest Thinking

By Jill Ambrose, MBA, BSN, RN and Jackie Becker

Women make up nearly half (47%) of the U.S. workforce and spend an estimated $15 billion more each year in out of pocket healthcare costs than their male colleagues. Employers looking to attract and retain top talent will need to better address women’s health needs through their benefits. Doing so starts with understanding the healthcare disparities women face, what health issues are driving up healthcare costs for women and the support they are looking for from their employers.

Historical Disparity in Healthcare

It’s well known to those within the healthcare industry that women’s health research lags far behind that of men. In fact, the Food and Drug Administration (FDA) and National Institutes of Health (NIH) did not require the inclusion of women in medical research and clinical trials until 1993. In recent years, women still accounted for less than half of clinical trial participants. Even today, we know so little about women’s health.

According to the NIH, only 6% ($3.1 billion) of its roughly $48 billion budget in 2024 went to women’s health research. Because we don’t understand women’s health, women are more likely to have negative experiences in the health system than men. In research conducted in 2022, 29% of women ages 18-64 who had seen a care provider in the past two years reported that their doctor dismissed their concerns. The inherit gender bias in the healthcare system keeps many women from seeking the care they need, leading to delayed diagnoses, which often cause diseases to be more complex, harder to treat and more costly for both the employer and employee.

Employers Need to Better Address Women’s Health Challenges

While employers have started to view women’s health differently from the rest of their benefits, there are still gaps in the main areas where women need more support. In the last decade, much of the focus on women’s health has been on fertility benefits.  However, when looking at the lifetime continuum of care for women employees, maternity care is only a small fraction of their overall health journey. That’s a significant gap considering that approximately one in five workers is a woman aged 45 or older, according to U.S. Bureau of Labor Statistics data from November 2025. Women employees are working through multiple life stages and need to be supported throughout all of them. Here are some of the trending women’s health areas that employers should be aware of and give greater consideration when designing benefits.

1. Reproductive Health

   One of the biggest trends happening in women’s health is the shift in the age range of women giving birth. According to data from the CDC, from 1990 to 2023 the fertility rate increased 71% for women ages 35-39 and 127% for women ages 40-44. It’s known that pregnancy-associated risks increase for women over 30. At the same time, infertility impacts one in six people globally. Between fertility care and later childcare, growing a family can bring an additional cost burden to many employees.

   Employers need to think beyond paid parental leave and consider addressing a broader spectrum of reproductive issues — such as fertility, surrogacy coverage, mental health care, flexible work arrangements, pregnancy loss leave, lactation needs, access for all genders/identities and more — to ensure benefits address financial, emotional and logistical challenges.

2. Cancer

   There are significant disparities when it comes to cancer incidence and death between men and women. Right now we’re seeing incidence rates for women continue to rise while they decline for men. For women under age 50 the incidence rate is 82% higher than that of men in the same age range. Black women continue to have the highest mortality rate for breast and uterine cancer, both of which are survivable when detected early. In fact, many of the cancers that most often affect women, such as breast, colorectal and cervical cancer, can be survived when detected in the earliest stages.

   Often, time and money are the main barriers preventing women from regular screenings. As cancer diagnoses rise in younger women, employers need to consider different approaches to make screenings and detection more accessible – including multi-cancer early detection offerings, offering specific time off for cancer screening or covering the cost of the diagnostic testing if needed after screening. Additionally, employers should consider removing age limits for specific screenings (e.g. colorectal and breast) and for heightened risk profiles (e.g. BRCA gene).

   Proportion of Total Cancer Deaths Averted Due to Screening and Removal of Precancerous Lesions (1975-2020)

   

   Source: American Association for Cancer Research, Cancer Progress Report 2025

3. Menopause

   Menopause is a condition that all women experience, and with women remaining in the workforce later in life, many will experience it while working. Recent surveys find that one in five women consider leaving the workforce due to their symptoms. Menopause is estimated to cost U.S. employers $26.6 billion annually in lost work time and medical expenses. Menopause symptoms greatly impact absenteeism and productivity. This is compounded by the fact that women have a hard time finding the resources they need and their symptoms go untreated. Only 35% of women ages 40-64 said that a health care provider discussed what to expect during menopause with them.

   Employers should consider women’s-health-specific vendor solutions that provide support and management of perimenopause and menopause symptoms.

4. Autoimmune Diseases

   About four out of five people with an autoimmune disease are women. This is an emerging area that is impacting a growing number of women in the workforce. With an autoimmune disorder, the immune system attacks healthy tissue, damaging or destroying it. Getting an autoimmune disease diagnosis can be a long and arduous process, taking an average of four to five years from the onset of symptoms. Employees often face costs from seeing multiple specialists, repeated lab work and lost time during periods of undiagnosed flares. From rheumatoid arthritis to multiple sclerosis, most autoimmune diseases are chronic with no cure, so treatments are aimed at managing symptoms.

   While science is improving the treatment of these conditions, the treatments are often costly. According to a study by the Integrated Benefit Institute, excess medical and pharmacy costs for employees with autoimmune diseases range from $2,200 to $33,500 annually. As science continues to progress, other advancements such as precision therapies could be initiated for disease management. Employers could consider enhanced flexibility and support for working arrangements to manage disease flare ups and appointments.

How Can Employers Better Support Women?

There isn’t a perfect or one-size-fits-all answer to addressing the totality of women’s health through employee benefits. But employers need to be more aware of the disparities impacting women’s health and consider women’s health issues in their plan designs. Now more than ever, women’s health benefits are becoming a strategic retention and growth tool. When women have benefits that address their entire continuum of care, they are more productive, feel valued and are more likely to remain with their employer.

Some ways employers can start investing in women’s health benefits include:

• Improving access to screenings – Some companies are starting to remove age restrictions for preventative cancer screenings to help encourage employees to get screened without having to worry about the cost or navigating authorization hurdles.
• Offering women-specific support – Some, but not all, enhanced areas of support include flexibility in working arrangements for women’s health management, specific time off for disease management, education and resources for the best approach for the continuum of care.
• Working with women’s health vendors – There are health vendors that have developed solutions aimed at addressing specific disparities in women’s health that employers can work with to offer more robust support.
• Working with the right broker – A broker with in-house population health, data analytics and communication expertise can help you implement a cost-effective plan that supports women employees and improves outcomes through education that encourages a proactive approach to healthcare, such as early screenings.

Another strategy employers might consider is moving to a self-funded plan. Self-funded plans create an opportunity to bring greater clinical sophistication to benefit strategy. By analyzing claims data at a population level, brokers and consultants can work with employers to anticipate emerging risks, enhance preventative care programs and introduce evidence-based solutions. This approach ensures decisions are driven by data, while reinforcing that employee privacy is not just protected – it is foundational.

The Conner Strong & Buckelew Advantage

Valuing female employees by striving to help them achieve health equity can support organizational growth. Our consultants, in-house population health experts and communication team have helped clients design and implement robust, data driven employee benefits plans that leverage data warehouses and utilize a benefits risk management approach to address the key health issues impacting women today.

Contact a member of our team today to learn how we can help you improve outcomes for your entire employee population.

By Daniel Brettler

Commercial Foreign Insurance

The Basics

Commercial foreign insurance policies (also known as foreign packages or multinational policies) typically extend standard business coverages — such as general liability, auto, employers‘ responsibility, property and other incidental coverages — outside the U.S., Canada and their territories. Coverage may be provided via admitted or non-admitted policies or both, although many countries mandate admitted policies written locally in their own language and currency. Regulations aside, employees working abroad are generally accustomed to policies that offer broad travel accident benefits provided by foreign-domiciled insurers on admitted policy forms.

Occupational-Related Structure

It’s important to understand that foreign commercial insurance policies typically cover occupational-related accidents and illnesses only. For example:

• If an employee traveling from France to Germany for a business meeting is injured in a car accident en route, liability and first party injury claims should be covered.
• However, if the employee is injured while visiting a friend’s home in Germany before the meeting, that loss is unlikely to be covered.
• Similarly, contracting an illness like the flu during travel may not be covered.

These examples illustrate the complexities and potential coverage gaps of foreign commercial insurance, which are particularly concerning in light of how employers’ responsibility and state-sponsored health programs operate outside the U.S. For example, U.S.-based employee benefits programs often exclude in-network benefits abroad, putting employees at financial risk and left to navigate the unfamiliar healthcare systems of foreign countries.

A multi-pronged approach that also includes business travel accident insurance can help close foreign commercial insurance coverage gaps and extend coverage even further.

Business Travel Accident Insurance

The Basics

Business travel accident (BTA) policies serve as primary insurance in certain situations and supplemental insurance in others. Key benefits include:

• Out-of-Country Medical Coverage: BTA acts as primary insurance when no other health insurance is available. For instance, if an employee is injured during personal time abroad and needs hospital care, BTA coverage may be the main source of protection.
• Immediate Access to Care: BTA policies typically provide the cash security required for employees to access treatment facilities outside the U.S. and assist the employee directly with event logistics.
• Supplemental Benefits: For occupational events, BTA provides additional lump sum benefits beyond those available from foreign commercial insurance or local state health programs. This includes high-limit benefits for loss of life, limb, sight, speech or hearing. BTAs can also supplement low-limit death benefits that may be available under workers’ compensation.
• Family Member Coverage: BTA can extend coverage to family members traveling with the employee, even for personal excursions, on a 24-hour basis.
• Additional Extensions: BTA coverage can also be expanded to include medical evacuation, repatriation, security evacuation, family reunion/trip cancellation expenses and more.

Integration With Travel Assistance Services

For large employee travel exposures some insurers partner with worldwide travel assistance providers. If a company has BTA and foreign commercial insurance, the insurer can recognize that single travel assistance provider to coordinate employee support during travel-related incidents. The provider manages employee needs and determines whether the claim falls under the BTA or foreign commercial insurance policy, so employees do not have to navigate the claim and coverage coordination process.

Special Considerations for Clinical Trials Travel

Organizations conducting human clinical trials, particularly those enrolling patients who travel with caregivers or family, can negotiate BTA policies to include coverage for participants and guests traveling for treatment. This is especially relevant for rare disease, cell and gene therapy and foreign clinical trials patients/participants traveling outside their home country.

Bottom Line

While commercial foreign insurance is essential for occupational exposures abroad, it does not fully address all risks associated with business travel —especially those occurring outside the scope of work. Business travel accident insurance fills these gaps, providing comprehensive protection for employees and their families — and offering valuable coverage extensions and support services. That’s why organizations with significant international travel should consider leveraging both types of coverage to ensure optimal risk management and employee well-being.

In addition to enhancing employee protection, a strategy that includes integrated business travel accident and commercial foreign insurance serves as a valuable and appreciated workforce benefit.

To learn more about how these coverages can work together for your organization, please contact the Conner Strong & Buckelew team today.

By Joseph M. DiBella and Greg Fanelli

The Challenge of Rising Healthcare Costs

American employers and plan sponsors [“employers”] are facing unprecedented, relentless increases in employee healthcare costs. According to the Business Group on Health’s Employer Health Care Strategy Survey, employer healthcare expenses have surged by more than 60% over the last decade, outpacing inflation and putting significant pressure on company budgets. Employers can no longer rely on minor plan tweaks or simply shifting costs to employees. The need for innovative, sustainable solutions is more urgent than ever. For many self-insured employers, reference-based pricing, sometimes known as indexed pricing, can be a game changer.

What is Reference-Based Pricing?

Reference-based pricing (RBP) is a transformative approach to managing healthcare costs. Unlike traditional health plans that negotiate network discounts on “chargemaster” (list) prices with hospitals, RBP sets payment rates based on an objective, independent benchmark — typically a set percentage above Medicare rates.

Focused on hospital facility costs, which are the primary driver of skyrocketing healthcare costs, the RBP model brings transparency, predictability and fairness to the hospital inpatient and outpatient healthcare purchasing process — and insulation against spiraling hospital chargemaster prices.

Employers adopting RBP to control hospital costs typically pair it with a traditional PPO physician network for non-hospital care, such as routine patient office visits, which only account for a fraction of employers’ overall health benefit costs.

How RBP Controls Costs

RBP directly addresses the root cause of high healthcare costs: the wide variation and lack of transparency in hospital pricing. As the comparisons below indicate, by anchoring payments to Medicare’s established rates, employers can dramatically reduce their hospital/facility-based care costs.

• National Averages: Traditional insurance plans typically pay about 250% of Medicare rates for hospital services. In contrast, RBP plans often pay 140 to 160% of Medicare rates — a substantial reduction and savings for employers based on a trusted, independent benchmark that also ensures hospitals are paid fairly.
• Real World Savings Example: One organization faced $92 million in billed charges over three years. Under a typical PPO plan with a 60% discount, they would have paid $36.8 million. Using RBP, the actual claims paid were $25.7 million — a savings of over $11 million in three years.*

Employers adopting RBP can see 20–25% reductions in hospital costs, creating room to reinvest in other employee benefits or business growth initiatives.

Hospital/Facility Acceptance

While there is some variance in facilities’ understanding and acceptance, most do accept RBP plans because:

• Reimbursement rates are higher than Medicare, fair, reasonable and designed to support facility profitability.
• RBP claim payments are made promptly, which relieves the stress on facility billing departments that are often overwhelmed and understaffed.

Advantages for Employers and Employees

RBP offers substantial benefits for employers and employees, including:

• Cost Savings: Self-funded employers can achieve reductions of 20 – 25% in their healthcare spend while employees benefit from lower out-of-pocket costs.
• Transparency: Employers and employees know exactly how much is paid for major services, removing the network discount guesswork.
• Broader Facility Access: Employees have access to more hospitals/facilities compared with a traditional plan.
• Potential for Improved Benefits: With lower costs, employers have more flexibility to reduce deductibles, maintain lower employee contributions or enhance other benefits.
• Fiduciary Protection: By tying payments to a recognized and trusted benchmark, employers can defend their plan choices as fair and reasonable.

Five Best Practices for Implementing RBP

Transitioning to RBP can pose employer and employee challenges which require thoughtful planning – with a special focus on the employee experience and plan adoption. Here are five things employers can do to help ensure a successful rollout:

1. Educate employees, dependents and internal teams via year-round resources like videos, FAQs, communication campaigns and meetings to explain RBP and answer questions.
2. Engage partner advocacy and legal teams to help employees with provider access questions, billing inquiries (including balance billing questions) and general benefits support. Comprehensive advocacy services also ease transitions by significantly reducing HR’s workload.
3. Phase-in the rollout by offering the RBP plan as an option alongside existing traditional plans, allowing employees to become familiar with RBP benefits and build confidence.
4. Pair the RBP plan with a traditional physician network, ensuring members have easy access to non-hospital care, such as routine office visits. This will promote preventive care and help avoid, reduce and manage future catastrophic costs.
5. Ensure robust compliance by aligning plans with ERISA requirements, other federal rules such as the No Surprises Act and relevant balance billing legislation.

The Importance of Broker Expertise

Successful RBP adoption demands expertise. An experienced broker plays a pivotal role in:

• Analyzing current claims and modeling RBP savings potential.
• Designing compliant plan documents and aligning with legal requirements.
• Selecting trusted third-party administrators (TPAs) and advocacy partners.
• Rolling out effective employee education and support programs.
• Monitoring outcomes and continuously improving the member experience.

With the right guidance, employers can avoid pitfalls, maximize savings and ensure a smooth transition for their workforce.

The Conner Strong & Buckelew Advantage

Conner Strong & Buckelew brings unmatched in-house expertise to reference-based pricing. Our team has guided organizations of all sizes — including complex, multi-site employers — through successful RBP transitions. We combine strategic plan design, robust advocacy and proven compliance support to deliver measurable savings and improved employee experiences.

If you’re ready to take control of your organization’s healthcare costs and empower your employees with a fair, transparent benefits strategy, contact us today.

*Example based on the actual experience of a Conner Strong & Buckelew client.

By Kate Kelly and Anthony Cirillo

Foster care agencies are at the brink. Increased litigation, rising insurance premiums and carriers exiting the insurance marketplace have left many agencies struggling to secure the coverage they need to protect themselves from significant exposures — at a price they can afford.

Contributing Factors

There are a number of factors contributing to the coverage crisis facing foster care agencies. These fall into two primary categories — societal and legislative changes and pressures on the insurance market.

Societal and Legislative Changes

• Today’s more litigious society and increased awareness stemming from greater media coverage and scrutiny has contributed to a surge in litigation and claims.
• Legislative changes, such as the Eliminating Limits to Justice for Child Sex Abuse Victims Act (2022) and the Child Victims Act (2019) in New York, have removed the federal statute of limitations for civil claims related to child sexual abuse.
• Several states – including New York, California, Pennsylvania and New Jersey – have expanded or created revival windows for filing previously time-barred cases, resulting in an influx of claims that are decades old and often result in significant payouts.
• Foster care agencies are facing higher caseloads and limited funding, contributing to overburdened systems that strain resources.

Insurance Market Pressures

• Rising claim frequency and severity have resulted in unsustainable underwriting losses for insurance carriers.
• Many insurers have exited the market and those remaining have significantly increased premiums, restricted coverage terms and reduced limit offerings.
• The shift in policy structures from “occurrence based” to “claims made” means that insurers are taking on risk for an unprecedented number of incidents that may have occurred 20 or 30 years ago.

Despite these challenges, liability coverage remains a legal requirement in most states, leaving foster care agencies struggling to secure the protection they need.

What You Can Do

With liability insurance harder to obtain, there are steps foster care agencies can take to help protect themselves, lower their risk and make themselves more attractive to insurers — beginning with building a strong foundation of risk management policies and procedures.

Comprehensive Policies and Procedures

Every foster care agency should maintain comprehensive, written policies and procedures covering child safety, abuse prevention, reporting requirements and staff and foster parent selection. These should be regularly updated to comply with all relevant regulations and best practices. Agencies must also establish clear protocols for incident reporting, documentation and follow-up actions — ensuring all responses and corrective measures are thoroughly recorded and retained. Additionally, contracts between the agency and foster parents should be properly executed and securely retained.

Vetting and Training Foster Parents and Employees

Agencies should implement and strictly adhere to procedures for thoroughly vetting all foster parents and employees — including background checks and referrals. They should also provide training on child safety and reporting requirements. Additionally, regular supervision and inspection of homes is essential to help identify potential risks early and often.

Acting Quickly to Remove Children from Questionable Environments

Many claims stem from allegations that the abused child was placed in an unsafe home, and the agency did not provide the correct environment for the child and/or did not remove the child quickly enough from an unsafe environment. Agencies need to act quickly to remove children from homes at the first sign that the environment is not safe.

How a Broker Can Help

The right insurance broker can be a valuable partner for foster care agencies. It’s important to work with a broker partner that has full access to the marketplace and stays abreast of emerging markets and/or alternative risk strategies to obtain coverage. Additionally, agencies should partner with a broker that has extensive experience and a proven track record of delivering coverage solutions, risk control guidance and claims advocacy to foster care agencies.

The Conner Strong & Buckelew Advantage

We work extensively with foster care agencies to develop and implement best practice risk controls that align with insurance carrier requirements for providing coverage — ensuring your agency is “best-in-class” and is represented as such in the insurance marketplace. Our deep relationships with domestic and emerging markets enable us to keep our pulse on the evolving landscape. Beyond traditional placement, we can also work with you to uncover creative solutions, such as captives, fronting solutions and/or risk retention groups. And when a claim occurs, our legal and claims advocacy teams will be right there to help ensure the most favorable outcome possible.

Contact a member of our team today to learn how our holistic approach can support your organization’s sustainable future.

By Franz Wagner,  Alexander Buzbee, and Jordan Carter

Behavioral health nonprofits face a multitude of challenges today. From low reimbursement rates and federal funding cuts to growing workforce shortages, many non-profit organizations have had to re-evaluate their long-term sustainability in an environment where competition from the for-profit sector continues to rise.

As a result of the current climate, many behavioral health nonprofits are looking at mergers and acquisitions (M&A) as a proactive strategy to preserve organizational longevity amidst escalating funding challenges. The recent news of the upcoming merger of Brightli and Centerstone, which will set an industry milestone with a combined annual revenue of $1 billion, makes a case for behavioral health nonprofits to consider combining resources with like-minded organizations.

In any M&A transaction, insurance and risk management are important factors to consider and plan for before, during and after an agreement is reached. An experienced insurance broker can serve as a crucial resource for nonprofits looking to acquire another company by helping to navigate merger risk management strategies — including due diligence and program integration.

Due Diligence: Assessing Total Cost of Risk

A core element of an acquiring company’s due diligence process should be determining the target company’s total cost of risk — or the sum of expenses incurred by the organization to manage risk that might be assumed upon completion of the transaction.

Calculating total cost of risk entails an assessment of the target company’s:

• Current Program Structure, Terms and Premiums
• Outstanding Liabilities – Exposures for Deductibles, Potential and Identified Uninsured Losses and Collateral
• Historical Information – Exposures, Coverage Terms and Loss Experience
• Current Risk Management Policies and Procedures
• Financial Condition

Once the acquiring organization has a picture of the target company’s total cost of risk, it can then be used as a lens for evaluating the target company’s financials to assess if all cost-related exposures have been adequately identified and captured. By conducting a thorough due diligence assessment with a focus on total cost of risk, acquiring companies can better ensure there will be no surprises after the acquisition due to potential unexpected cost variances from a current or prior insurance program. Further, this information can be used to establish a post-merger/acquisition insurance cost proforma that can serve to identify any ongoing insurance-related cost efficiencies.

Similarly, it also pays for target companies to have a full understanding of their own total cost of risk so they can correct course on issues that may become acquisition obstacles or hurt their appeal to potential acquirers.

Assessing total cost of risk as part of the due diligence process requires extensive data analytics and coverage expertise resources that might not be present within a behavioral health nonprofit’s leadership team or staff. That’s where a broker with substantial M&A expertise can deliver value.

Program Integration: Risk Management and Insurance Planning

As part of due diligence, an acquiring company should take a closer look at any disconnects or issues uncovered and determine strategies to address them. For example, addressing legacy claims under claims-made policies or assessing the need for representations and warranties insurance (RWI) to protect the buyer from inaccurate statements or seller solvency risks.

At this point, the acquiring company should also map out the structure of the combined company’s risk management and insurance programs to ensure there are no gaps in coverage and to maximize the efficiencies in both programs. In some cases that might mean keeping the insurance separate for a time or it could mean combining some or all policies at close. The acquiring company might also consider what, if any, additional risk management, claims management or safety and loss prevention measures should be implemented.

There isn’t a one-size-fits-all approach to M&A risk management and insurance for nonprofits. Working with an experienced broker partner with an in-depth understanding of M&A transactions will help acquiring organizations ensure they implement the best solutions for their needs.

The Conner Strong & Buckelew Advantage

Insurance and risk management are essential in M&A transactions. Conner Strong & Buckelew has deep expertise to guide clients through every stage of the process, serving as an extension of their team and providing support before, during and after the deal. Starting with a comprehensive due diligence process focused on the total cost of risk, our team delivers holistic solutions tailored for behavioral health nonprofits, helping organizations achieve successful and sustainable deal outcomes to support their long-term growth goals and objectives. Ready to elevate your M&A strategy? Contact us today to partner with experienced professionals committed to your success.

By Lovedeep Saini, Ph.D. and Shalin Dave

As artificial intelligence (AI) continues to evolve, there will be a massive shift in the way businesses conduct employee benefits planning and administration. AI and machine learning algorithms are able to continuously sift through huge amounts of data quicky and in real-time, enabling more automation and supporting deeper insight into employee population and claim data. Today, human resources departments are starting to test AI tools — implementing things like chatbots or smart recommendations. But these use cases only scratch the surface of what AI is and will become capable of in employee benefits.

Enhanced Data Analysis

When implemented strategically, AI can offer significant advantages for plan design and benefits administration. However, as these tools continue to evolve — and the data analysis they provide becomes more accurate — it’s important to remember that AI is a tool. It should be thought of as “augmented intelligence” — not an all-knowing machine. Its purpose is to help plan administrators make more informed decisions.

Here are a few examples of how AI will impact, streamline and optimize plan design and administration:

• Actionable Population Health Intelligence – AI will enhance employers’ ability to analyze integrated employee data to identify emerging health risk trends across their entire workforce — before they drive up claims. Self-insured employers in particular stand to gain unprecedented visibility into population health trends, which will support more strategic and cost effective plan designs.
• Targeted Claim Prevention – By providing greater visibility into population health at the individual level, AI will also support targeted interventions and personalized employee healthcare solutions that can prevent high-cost medical events. By helping to orchestrate members’ health journeys rather than simply processing claims after care is delivered, AI will drive overall plan cost savings while improving member health outcomes.
• Plan Utilization and Optimization – Richer data through AI supports plan administrators’ ability to track utilization of wellness and other programs in real time — and make more informed decisions about program improvements or communication strategies. And with future AI advancements, benefits packages could automatically adjust features, networks and incentives in real time based on utilization, costs and health outcomes — without waiting for annual renewals.
• Reference-Based Pricing Healthcare Models – AI is starting to show up in reference-based pricing strategies (also known as indexed reimbursement strategies) to help analyze market data such as index cost fluctuations in real-time. As this use case continues to evolve, it will support more dynamic price adjustments and help lay the groundwork for negotiations and plan customization.

For employees, the advantages of deeper, more dynamic data through AI will translate to simpler, more supportive everyday experiences — from quicker and more robust answers from AI chatbots, to timely reminders for health checkups, to personalized guidance on which benefits fit their needs best.

The Keys: You Need Good Data and Human Touch

Getting the most out of AI requires access to comprehensive, accurate employee health data — ideally integrated data that encompasses medical claims, pharmacy utilization, biometric data, workplace analytics and behavioral indicators. For this reason, AI’s ability to influence plan administration and design is fully maximized when companies are in a captive or self-funded model, where they have direct access to the detailed data required to train algorithms and uncover patterns down to the individual member level.

That doesn’t mean fully insured employers can’t benefit from applications focused on employee engagement, such as benefits navigation, member enrollment, communications and population health insights. For example, generative AI tools can be designed to answer basic benefits questions or help members with the enrollment process.

Regardless of funding structure, successful AI deployment and implementation require human oversight. AI is a tool designed to augment human expertise in benefits strategy, not replace it. Employers must work with benefits advisors who understand strategic plan design, AI capabilities and regulatory requirements to ensure responsible implementation that protects employee privacy while maximizing business outcomes.

The Conner Strong & Buckelew Advantage

As AI transforms employee benefits employers need strategic partners who understand its opportunities and challenges. Conner Strong & Buckelew is already helping clients build strong data foundations and governance that will prepare them for the next generation of AI supported benefits programs. Our in-house benefits experts and dedicated AI analytics team monitor AI trends, advise on regulatory and privacy issues and work with employers to chart a path for AI-driven benefits strategies.

If your organization is ready to explore how the strategic use of AI can support plan design, cost containment and improved health outcomes, reach out to a member of our team today.

By Ed Cooney

Signed into law on October 29, 2024, Act 121 amends Pennsylvania’s Workers’ Compensation Act to address mental health coverage for first responders, specifically focusing on post-traumatic stress injury (PTSI), often referred to as “PTSD.” It will take effect on October 29, 2025.

Key Provisions

EFFECTIVE DATE

Provisions apply to claims filed on or after October 29, 2025, and injuries occurring within five years before that date (October 29, 2020).

COVERAGE FOR PTSI

Act 121 allows first responders, including firefighters, police officers, and emergency medical services personnel, to file workers’ compensation claims for PTSI resulting from exposure to traumatic events in the course of their employment.

PRESUMPTION

The law does not create an automatic presumption that PTSI is work-related (unlike California’s SB 542). Instead, first responders must still demonstrate that their PTSI is directly related to their job duties.

DEFINITION OF FIRST RESPONDER

The act clearly defines which occupations are covered, including paid and volunteer firefighters, law enforcement officers, and EMS personnel.

Implications for Clients

ACCESS TO BENEFITS

First responders in Pennsylvania now have a clearer and broader path to seek workers’ compensation benefits for PTSI, but they must provide evidence linking their condition to a work-related traumatic event.

NO AUTOMATIC PRESUMPTION

Unlike some other states, Pennsylvania requires proof of causation; the burden remains on the employee to show the connection between their mental health condition and their work.

SUPPORT FOR MENTAL HEALTH

The law recognizes the unique mental health challenges faced by first responders and aims to support them in accessing care and benefits.

Before Act 121 in Pennsylvania

Pennsylvania courts recognized mental-mental injury claims (where a psychological injury arises without a physical injury) could be compensable. However, the burden of proof was high and there was no presumption, which made it especially difficult for first responders. Claimants had to show:

• The psychological injury (like PTSD) was caused solely by abnormal working conditions (i.e., conditions significantly different from what others in the same occupation face).
• The mental health condition was diagnosed by a medical professional and was directly caused by the job. For first responders regularly exposed to trauma, courts often ruled such conditions were “normal” for the job, so claims were denied. Some rare claims were successful—but only in extraordinary circumstances, like a mass casualty event, death of a coworker, or a particularly gruesome scene.

Now With Act 121

Act 121 removes barriers, making PTSI claims for traumatic exposure on the job significantly more viable and accessible. The Act does not create a presumption but removes the “abnormal working conditions” barrier and defines “qualifying traumatic events” for which claims can be made.

THE FIRST RESPONDER MUST SHOW

• They were exposed to a specific traumatic event on duty;
• They were diagnosed with PTSI by a licensed physician or
  psychologist; and
• There is a causal connection between the event and their mental
  health condition.

“QUALIFYING TRAUMATIC EVENTS” MEANS AN INCIDENT OR EXPOSURE

• Resulting in serious injury or death;
• Involving a minor who has been injured, killed, abused or exploited;
• Involving an immediate threat to the life of the claimant or another individual;
• Mass casualties; or
• Responding to crime scenes for investigations.

Key Strategies for Managing Act 121 PTSI Claims

CLAIMS MANAGEMENT AND REPORTING

TPA Clear Designation
Ensure your third-party administrator (TPA) is fully briefed on Act 121 and has a clear process for designating, coding and tracking PTSI claims. This will help ensure these claims are handled consistently and in compliance with the law.

Expansion of Injury Reporting Forms
Consider updating or expanding your injury/incident reporting forms to specifically include mental health and PTSI-related questions (to include trauma related and psychological exposures). This can help capture relevant details early and support proper documentation for Act 121 claims.

Review Union Contracts
Review collective bargaining agreements to identify any provisions related to mental health, workers’ compensation, or return-to-work (RTW) policies. Ensure that your approach to Act 121 claims aligns with contractual obligations and that union representatives are informed about the new law.

TRAINING AND WELLNESS INITIATIVES

Supervisor Training
Train supervisors and managers to recognize signs and symptoms of PTSD/PTSI and to understand the requirements of Act 121. This includes knowing how to respond to reports of traumatic incidents and how to support affected employees.

Wellness Programs
Enhance or implement wellness programs that address mental health, resilience, and stress management. Promote resources such as employee assistance programs (EAPs), peer support, and confidential counseling services.

CLAIMS MANAGEMENT BEST PRACTICES

Prompt Independent Medical Evaluation (IME)
Arrange for an IME as soon as possible when a PTSI claim is filed. Early evaluations can help clarify diagnosis, causation, and treatment needs, and may assist in managing claim duration and costs.

Monitor Medical Progress
Closely track the claimant’s medical progress and compliance with prescribed treatment. Maintain regular communication with treating providers to ensure appropriate care and timely updates.

Review Offsets
Evaluate whether benefits from other sources—such as disability insurance or pension plans—may offset workers’ compensation payments. Coordinate with your TPA and legal counsel to ensure proper application of offsets.

Return-to-Work (RTW) Options
Explore RTW opportunities, including light-duty assignments for employees recovering from PTSI. Work with medical providers to determine appropriate accommodations and facilitate a safe, supported transition back to work.

Early Intervention and Communication
Upon notice of a traumatic event or claim, reach out to the employee promptly to express support, explain the process, and provide information about available resources.

Dedicated Claims Contact
Assign a dedicated claims manager or point of contact for PTSI claims to ensure consistency, build trust, and facilitate communication between all parties.

Documentation and Recordkeeping
Encourage thorough documentation of all potentially traumatic incidents, including date, time, location, involved parties, and immediate response actions. Maintain claim files and keep organized records of all communications, medical reports, witness statements, and investigative materials related to each claim.

Data Analysis and Trend Monitoring
Track claim trends and analyze data on PTSI claims to identify patterns, root causes, and opportunities for prevention or process improvement.

CHALLENGING THE CAUSATION AND EXTENT OF DISABILITY

Course of Employment
Assess whether the reported traumatic event(s) occurred in the course and scope of employment. Gather incident reports, duty logs, and witness statements to confirm work-relatedness.

Disability Status
Review medical evidence to determine if the employee is totally disabled or capable of performing light-duty work. If medical records support eligibility for modified duty, document this and offer appropriate accommodations.

Surveillance and Background Checks
Where appropriate and lawful, consider surveillance or review of pre-employment and medical records to assess the validity of the claim and identify any pre-existing conditions or non-work-related factors.

Conflicting Medical Reports
If there are discrepancies between medical opinions regarding the diagnosis, severity, or timeline of PTSI, obtain additional expert opinions or request clarification from treating providers.

Witness Statements
Collect statements from coworkers, supervisors, and others who may have observed the incident or the employee’s behavior before and after the alleged traumatic event. These can be critical in establishing facts and timelines.

By Monica Attanasi, AIC and Colleen Vallen, CPA, CFF

Loss events, no matter the type, are disruptive, complicated and burdensome for any company in any industry. In the aftermath of a catastrophic event like a fire, cyber-attack or major weather event, businesses need to focus on mitigating the impact of the loss, resuming operations, serving customers and supporting employees — not draining resources managing a claim.

Working with an insurance brokerage that has an integrated forensic accounting affiliate can be a game changer. While the role of the forensic accountant varies based on the claim and business needs, a forensic accountant working together with an experienced claim advocacy team eases the disruption and burden on the company, so it can focus on the business while the integrated claim team handles the complexities and maximizes the claim recovery.

What are Forensic Accountants?

Forensic accountants are involved in quantifying the full impact of an event — including analyzing the cost of repairs/replacements, business income/lost profits, and increased or extra expense. This is a complex process requiring an investigative and analytical mindset to accurately analyze, evaluate and project losses. Working hand in hand with claim advocacy consultants, forensic accountants analyze documentation and information, prepare financial modeling to develop a loss projection, and prepare comprehensive reports to provide an in-depth understanding of the business and loss impacts to the insurance carrier. Forensic accountants also aid in responding to complex requests for information, analyzing and evaluating calculations prepared by the insurance company’s accountants, and in some cases, serving as expert witnesses.

A Holistic Approach to Claim Resolution

Every business and loss event is different, so there is no one-size-fits-all approach. Calculating and documenting a claim is not a simple fact gathering exercise. It is a process that requires in-depth understanding of financial information, complicated financial analyses and modeling, effective communication, creativity and strategy.

Critical to this process is the ability to understand and analyze the financial impacts of the loss and articulate the story behind the numbers. In addition to preparing financial analyses, forensic accountants use their investigative skill set to gain an understanding of the business, market and the industry in which the business operates to present a holistic picture to the insurance carrier. For example, knowing the company was planning to add a new division, launch a new product or acquire a new location might not be reflected in the historical financial data, but this information is incredibly relevant to accurately quantify business income and other financial losses.

Forensic accountants, in partnership with seasoned claim advocates, go beyond the numbers, using their expertise and experience to marry the story of a business with its financial numbers. In large property and other types of claims, the forensic accountant’s skills validate the process and lend credibility to the numbers. This can make a significant, positive impact on the claim outcome.

Forensic Accounting in Action

Real estate is an industry where catastrophic losses are common, due in part to large portfolios with geographic footprints that span the country and include catastrophe-prone areas. For a national real estate development and management company, the claim advocacy team at Conner Strong & Buckelew and the forensic accounting team at J.A. Montgomery worked together to drive a successful claim outcome.

The Loss Event

One of the company’s properties, located in New Jersey, experienced severe damage in 2021 from Hurricane Ida — a devastating category 4 hurricane that caused $75 billion in damage across 22 states. From day one, the forensic accounting and claim advocacy teams worked together to manage the property damage, business interruption and extra expense components of the claim. This included managing submission of the building spend package and preparing business income and extra expense claim calculations.

Key Challenges

The forensic accountants addressed several complications during the process. On the building spend side, the ongoing building spend required numerous updates and reconciliation along with the review of thousands of invoices and an allocation process that required intensive document review and client discussion.

On the business income front, the increased demand for apartments in New Jersey due to the COVID-19 pandemic added complexity to an already challenging calculation. This required performing an in-depth review of the market to validate the significant increases in rental costs that was not captured in the company’s historical data. The forensic accounting team was able to bring that market analysis forward in the narrative and calculated losses submitted to the carrier.

The Result

Our integrated claim advocacy and forensic accounting approach yielded a favorable $10 million+ claim settlement for the company. This included claims for recoverable depreciation and business income totaling $3.5 million, which were complex, challenging to document and subject to thorough review and analysis by the insurance company. As a result of the integrated forensic accounting and claim advocacy approach, the claim settlement was approximately 25% higher than it would have been with a standard claim submission and processing approach.

Maximizing Claim Outcomes and Minimizing Work

Catastrophic losses can hit at any time and can impact companies in different ways. Working with a brokerage that fully integrates forensic accounting with claim advocacy from end-to-end can translate to a more favorable claim outcome to help your company get back to business.

At Conner Strong & Buckelew, we provide a holistic claims strategy that starts from day one and doesn’t end until the claim is resolved. By partnering with our owned forensic accounting affiliate, J.A. Montgomery, whenever possible, we’re better able to tell your full story and maximize your claim settlement.

Contact a member of our team today to see how our holistic approach to claim management can help you be prepared when a loss occurs.

An Opinion Piece

By Joe DiBella

Overview

The No Surprises Act (NSA) took effect January 1, 2022, and was designed to protect patients from surprise medical bills, particularly in emergency and out-of-network (OON) situations. While successful in curbing balance billing for consumers, the implementation of the law has led to significant unintended consequences for employer-sponsored health plans, particularly those that are self-funded. The Independent Dispute Resolution (IDR) process, a core element of the NSA, has been marked by high volume, provider-favorable outcomes, and substantial administrative burdens. This summary outlines the law’s mechanics, its financial and operational impact on employers, and the urgent need for reform.

UNDERSTANDING THE NSA AND THE IDR PROCESS

Under the NSA, when a patient receives OON emergency care or services from ancillary providers at in-network facilities, the provider and health plan must negotiate reimbursement without billing the patient beyond in-network cost sharing. If no agreement is reached, either party may initiate the IDR process, wherein a certified arbitrator selects one party’s proposed payment. Initially, the “Qualified Payment Amount” (QPA) was intended to serve as the primary benchmark in IDR cases. The QPA represents the median in-network rate for a service in a geographic area. However, legal challenges and court rulings have allowed arbitrators to weigh other factors more heavily, such as provider experience and case complexity. Right or wrong, this has diluted the intended cost-containment role of the QPA.

THE DISPROPORTIONATE IMPACT ON EMPLOYERS AND PLAN SPONSORS

Employers and Plan Sponsors, and particularly those with self-funded plans, are bearing the brunt of NSA-related cost increases. The financial impact arises from both the direct cost of arbitration awards and the indirect administrative expenses tied to compliance and dispute resolution. Here are some data points that put the added costs into perspective:

1. Provider-Favored Arbitration Outcomes

• Providers win an estimated 85% of emergency-related IDR cases.
• Average payment awards in these cases are roughly 2.7x the QPA, with some cases reaching as high as 4x Medicare rates.

2. High Prevalence of Emergency Room Disputes

• Approximately two-thirds of all IDR disputes relate to emergency services.
• From Q1 2023 to Q2 2024, about 1.24 million surprise billing disputes were filed, over 40% of which resulted in arbitration.

3. Escalating Employer Costs

• QPA (benchmark): $600
• Typical Award: $1,620 (2.7x the QPA)
• Incremental Cost/Case: $1,020

• Annual Impact: $204,000 in additional claims cost
• IDR Fees: $315 to $1,300 per case = $63,000 to $260,000 annually

4. National Cost Exposure

• With an estimated 500,000 ER-related disputes resolved over 15 months, total added cost to the system could be as much as $500 million to $700 million annually.
• Administrative and certified IDR entity fees alone add another $105 million or more.

5. Administrative Burden and Compliance Risk

• Employers must ensure TPAs comply with IDR timelines and manage disputes. The costs of which are simply passed back to the employer.
• Compliance involves tracking QPAs, submitting documentation, and responding within strict periods.
• Legal volatility due to shifting federal court rulings has made consistent compliance difficult.

NSA REFORM PROPOSALS

There is growing recognition of the strain the NSA has placed on employers and plan sponsors. Legislative and regulatory proposals are emerging from Congress and the administration. H.R. 9572 in the U.S. House offers a series of fixes intended to rein in payments that are far in excess of the QPA which lead to increased financial exposure to self-funded plans. Below is a summary of some of the proposals in play:

Recommendations for Employers and Plan Sponsors

Employers and plan sponsors need to act and advocate for meaningful reform to the NSA. Left as is, the law may actually drive up providers leaving networks and increasing the probability of higher out-of-network usage overall. Conner Strong & Buckelew will be advocating for fixes to the law that does not undermine its intent but does fix the enormous new costs the law has shifted to employers and plan sponsors. Some immediate steps group health plans should consider include:

• Making IDR and QPA assumptions in budget models and reserves.
• Audit TPA processes to ensure IDR compliance.
• Consider network expansion and steerage strategies to limit OON exposure.
• Monitor federal regulatory updates and prepare to comment on proposed rules.
• Work with trade groups and lobbying organizations to advocate for legislative changes to fix the issues and flaws with the NSA.

Conclusion

The NSA has succeeded in reducing patient exposure to surprise medical bills, but at a substantial and rising cost to employer-sponsored health plans. The current IDR system disproportionately favors providers and leads to awards significantly above market benchmarks. Combined with administrative burdens and legal uncertainty, the system places employers at risk of financial strain and compliance errors. Employers and plan sponsors should actively advocate for reforms that restore the QPA as the primary benchmark, streamline the IDR process, and reduce fee exposure.

SOURCES:

• CMS.gov, IDR Quarterly Reports
• HealthSystemTracker.org, Kaiser Family Foundation
• ACEP.org, American College of Emergency Physicians
• CommonwealthFund.org, Health Affairs
• Academic.OUP.com, Oxford University Press analysis
• AHIP.org, Hall Benefits Law
• SLPHealthcareUpdate.com, Ogletree Deakins
• CBO, Congressional Budget Office Estimates
• Claritev.com, IDR Market Data
• FY2025 US Budget Summary (HHS Implementation Line Items)