A quick orientation

• How often do you typically run benefits renewals for major lines of coverage? Options: Annually, Every 18 months, Every 2 years, On ad hoc schedule
• Which stakeholders do you typically involve in renewal strategy discussions? Options: CHRO / Head of People, VP Total Rewards, CFO / Head of Finance, HRBP for business units, Procurement, General counsel, Other
• Who currently owns the renewal calendar and vendor communications within your organization? Options: Total Rewards team, HR operations, Procurement, External broker, Shared between teams, Other
• Tell us the renewal that triggered this review and one sentence on why leadership felt it was surprising

Where the money actually leaks

• What single renewal outcome would make your board question the current advisory approach? Options: Repeated double digit increases, Unexplained premium variance vs peers, Failure to show alternative financing scenarios, Lack of documented fee-only disclosure
• How large is the three year average renewal increase that pushed this onto your agenda? Options: Under 5 percent, 5 to 7 percent, 8 to 12 percent, Over 12 percent
• Where does the CFO apply the most pressure when renewals exceed plan, cost center, or plan forecasts? Options: Headcount targets, Operating budget, Board reporting, Reserve and cash planning, Other
• Rate the likelihood that incumbent recommendations are influenced by commission or placement relationships Options: Very likely, Somewhat likely, Unclear, Unlikely
• If independent analysis showed a 6 percent normalized savings, would you be prepared to move that week? Options: Yes, move immediately, Need final approvals first, Only after pilot validation, Unlikely to move

Claims and benchmarks that tell the truth

• When you compare your claims to industry peers, where do you expect the largest misalignment to show up? Options: Inpatient vs outpatient mix, High cost claimants, Pharmacy spend, Professional fee variance, Network unit cost
• Describe your current claims extract, the format delivered, and the person responsible for producing it
• Who maintains the claims to enrollment mapping and can validate member linkage if questions arise? Options: Internal HRIS owner, Internal benefits analyst, Broker or third party administrator, TPA support team, Not yet assigned
• Rate the cleanliness of member identifiers, enrollment links, and episode attribution in your files Options: Very clean, ready to use, Generally clean with exceptions, Significant cleanup required, Unknown / have not audited
• Is your team willing to provide raw claims and enrollment files within 14 days of an engagement agreement, under a data authorization? Options: Yes, Yes with de identification, Need two to four weeks, No, cannot provide

Design trade offs that rarely get discussed

• Which benefit design change would most reduce cost but also risk competitiveness for your hardest to fill roles? Options: Higher employee cost share, Narrowed network, Prior authorization / utilization controls, Pharmacy formulary changes, Other
• Give an example of a plan design change you implemented in the last three years and the hiring or retention impact you observed
• What specific metrics do you watch to judge benefits competitiveness in your target hiring markets? Options: Offer acceptance rate, Time to fill critical roles, External market surveys, Employee satisfaction scores, Other
• Name the role accountable for recruiting thresholds and how benefit competitiveness is escalated during hiring freezes or offers
• If a recommended design change reduced total cost by 8 percent but required midyear system updates and communications, would you implement it? Options: Yes, with change management support, Only at annual renewal, No, avoid midyear changes, Depends on affected business unit

Who holds the decision levers

• Name the leader who can block a material benefit change at renewal
• Describe the approval workflow and typical lead times to move a recommendation through finance, legal, and executive review
• Estimate the time legal review usually requires for commercial terms, SOW, and vendor agreements Options: Less than 1 week, 1 to 2 weeks, 2 to 4 weeks, Over 4 weeks
• Are there executive committees or board reviews that must sign off before implementation of negotiated plan changes? Options: Yes, board level, Yes, executive committee only, No formal committee, Varies by plan change
• Would you pause negotiations if key approvers are unavailable in the three week window before renewal? Options: Yes, pause, Proceed with provisional approvals, Escalate to alternate approvers, Undecided

Alternatives you are weighing right now

• List the conditions under which you would keep your incumbent broker despite repeated above budget renewals
• Select the alternatives you are actively evaluating alongside an external consultant Options: Stay with incumbent and negotiate, Self fund / change financing, Pharmacy carve out, Switch to new broker, Run a competitive RFP, Other
• Has anyone internally proposed solving renewals without an outside partner, and if so what was the proposed approach? Options: Yes, internal analytics and procurement, Yes, use existing broker but insist on fee disclosure, No internal proposal yet, Other
• Outline the proof or evidence that would make you stay with the current approach rather than change vendors
• Would a formal savings guarantee or alternative pricing commitment from the incumbent make you stay? Options: Yes, definitely, Maybe with audit rights, Unlikely, Depends on guarantee terms

Operational readiness and data gatekeeping

• Identify the single technical or data gap that would stop the project before any analysis begins
• Do you have a named data owner who can authorize delivery of claims and enrollment for analysis? Options: Yes, named and available, Yes, but limited availability, No named owner yet, Third party administers access
• List the systems that currently hold enrollment, medical and pharmacy claims, and payroll
• Estimate how long it takes your IT or vendor partners to provision secure file transfers or API access for benefits data Options: Under 3 business days, 3 to 10 business days, 11 to 21 business days, Over 21 business days
• Are there privacy, compliance, or regulatory approvals that typically delay data sharing for benefits projects in your environment? Options: Yes, significant approvals, Yes, minor approvals, No major approvals, Unsure
• Can your security and privacy team sign a standard data authorization and transfer agreement within 21 days? Options: Yes, Yes with review, No, will take longer, Not permitted

What success looks like and how you will accept it

• Specify the metric and threshold that would secure sign off on this engagement
• Identify the stakeholder who must confirm team continuity and named leads before you will proceed Options: VP Total Rewards, CFO, CHRO, Procurement lead, Other
• Provide examples of the evidence you require to accept benchmarking and model results, for example audit files, methodology notes, or raw comparator listings
• Confirm whether a signed acceptance checklist at delivery will be the billing trigger you expect Options: Yes, acceptance triggers billing, No, billing tied to milestone only, Need alternate billing terms
• Can procurement commit to executing contracts within five business days if agreed targets are met and terms are final? Options: Yes, Only with expedited review, No, will take longer, Unsure

Timing, next steps, and a clear path to start

• Tell us the conditions that would make you accelerate a decision to sign within 30 days
• Provide the key dates or blackout periods we must avoid when scheduling workshops and negotiation windows
• Include the job titles that should be invited to the kickoff to ensure momentum, and note any substitutes
• Select the earliest acceptable start window for workshops and data transfer Options: Immediately / within 2 weeks, 2 to 4 weeks, 1 to 2 months, More than 2 months out
• Choose whether you want a sample statement of work and standard data authorization to review before the first workshop Options: Yes, please send both, Send SOW only, Send data authorization only, No, review later
• Confirm whether you can commit to a decision within 45 days if we start within your acceptable window and you authorize data Options: Yes, commit to 45 days, Need longer window, Decision depends on pilot results, Unsure

• Claims Data Validation and Reconciliation
• Benchmark Cohort Definition and Slice Selection
• Plan Design Trade-offs and Prioritization
• Advisor Independence and Compensation Confirmation

• Insert the approved disclosure language into the proposal and negotiation packet.
• Recap validated data and benchmarking anchors
• A documented prioritized shortlist of plan design packages for modeling is agreed.
• For each shortlisted package, directional cost, member experience, and implementation constraints are recorded.
• Modeling scope and assumptions required for each package are confirmed.
• Document the shortlisted plan design packages with the scoring rationale and modeling assumptions.
• List systems, vendor, and communications implications required to implement each package.
• Confirm timeline and data inputs for detailed cost modeling of each package.
• Present standard independence and fee-only disclosure
• The seller's independence model and fee structure are confirmed in writing.
• Any potential conflicts are documented with agreed mitigation or disclosure steps.
• Final disclosure language to appear in client-facing materials is approved.
• Publish the signed independence disclosure and fee structure document for the engagement.
• Compile a list of any historical or perceived conflicts with the evidence and agreed mitigation steps.
• Confirm data inventory and delivery date
• A definitive inventory of received files and the list of any missing fields or files is accepted.
• A documented discrepancy log with severity classification and root-cause hypotheses is produced.
• Clear remediation tasks and objective acceptance criteria for the validated dataset are agreed.
• Deliver a reconciled claims file meeting the agreed acceptance criteria and file format.
• Document each discrepancy with the evidence required to resolve it and target completion dates.
• Schedule a follow-up data remediation check-in within the agreed timeline.
• Clarify benchmarking objectives and constraints
• A final list of benchmarking cohorts and slices is documented and accepted.
• Normalization and adjustment rules for benchmarking are agreed and recorded.
• Any remaining data needed to finalize slices is listed with delivery deadlines.
• Publish the final benchmarking cohort definitions and slice specifications.
• Provide any missing demographic segmentation files required for slices.
• Confirm the peer industries and regions to include in the benchmarking run.
• Sample reconcile eligibility and enrollment
• Present candidate cohorts and slice options
• Present candidate design levers and expected effects
• Review known third-party relationships and historical arrangements
• Evaluate each lever by cost direction, member impact, and complexity
• Validate claims completeness and coding consistency
• Assess perceived conflicts and mitigation options
• Workshop cohort selection and exclusions
• Prioritize and select top design packages for modeling
• Agree final disclosure language for client materials
• Identify and categorize data anomalies
• Agree normalization and adjustment rules
• Agree remediation tasks and acceptance criteria
• Confirm additional data needed for final slices

• Normalize and Clean Medical and Rx Claims Data
• Deliver Peer Benchmarking and Comparative Analytics
• Design Optimized Plan Options with Cost/Benefit Tradeoffs
• Build Actuarial Pricing Models for Proposed Designs
• Run Carrier RFP and Collect Competitive Bids
• Negotiate Renewal Rates and Contract Terms with Carriers
• Execute Pharmacy Carve‑Out Transition
• Implement Reference‑Based Pricing Program
• Convert to Self‑Funded Plan and Place Stop‑Loss
• Draft Employee Communication Packages and Enrollment Materials
• Configure Benefit Administration System and Migrate Plan Files
• Coordinate Carrier EDI, ID Card, and Eligibility Changes
• Deploy Ongoing Claims Monitoring and Savings Dashboard

Normalize and Clean Medical and Rx Claims Data

• Provide the formats and file names for the claims extracts you will supply (for example: member_level_claims_YYYYMM.csv, Rx_claims_NDC.csv).
• List the data fields included in your member-level medical file (examples: member ID, service date, CPT/HCPCS, ICD-10, allowed amount, paid amount, facility NPI).
• Which pharmacy data elements are available from your PBM export (examples: NDC, days supply, ingredient cost, dispensing fee, Rx BIN/PCN)? Options: Full NDC-level detail with ingredient costs, Claim-level aggregates only (no NDC), PBM paid amounts plus rebate summaries, Not sure / need help extracting
• Attach or describe any known data issues we should expect (examples: duplicate claim IDs, missing NPI, zero allowed amounts, overlapping claim lines).
• Specify the historical period you will provide for normalization (select the plan years or number of months of claims). Options: 12 months, 24 months, 36 months, Other
• Confirm the membership file cadence and key fields we will receive (examples: monthly eligibility CSV with member ID, coverage tier, hire/termination dates, COBRA flags). Options: Monthly feed with full fields, Quarterly snapshot only, Ad hoc snapshots, I need help defining the feed
• Indicate the accuracy threshold you require for cleaned claims before acceptance (examples: <=2% duplicate rate, >98% member match rate against eligibility). Options: >98% member match, >95% member match, Acceptable with documented exceptions
• Identify any regulatory or plan-document constraints that affect claims normalization (examples: ERISA plan year boundaries, carve-outs, retroactive premium loads).
• Describe who in your team will own secure file transfer (SFTP credentials) and who is authorized to approve data attestations.

Deliver Peer Benchmarking and Comparative Analytics

• Which benchmarking slices are highest priority for you (examples: industry SIC/NAICS slice, company size band 1k-5k, 3-digit ZIP region)? Options: Industry + region, Company size only, Detailed demographic slices (age/gender), Custom cohort
• Provide the target peer comparisons needed for board review (examples: top 10 peers in same NAICS, regional peer median, national top quartile). Options: Regional median, Industry median, Top quartile, Custom peer list
• Specify any utilization or cost metrics that must be included in the benchmarking deliverable (examples: PMPM medical, Rx PMPM, inpatient days per 1,000, ER visits per 1,000). Options: Medical PMPM, Rx PMPM, Inpatient days/1,000, ER visits/1,000, Custom metric
• Identify the population segments that should be benchmarked separately (examples: active employees, COBRA, retirees, dependent children). Options: Active employees, Dependents, Retirees, COBRA/terminated
• Indicate whether you require peer benchmarking against our national database sample sized to at least X covered lives per slice and specify the minimum covered lives threshold you expect. Options: Minimum 1,000 covered lives per slice, Minimum 5,000 covered lives per slice, No minimum required
• Describe any cost or outcome benchmarks that must be included for pharmacy (examples: generic dispensing rate, specialty spend %, rebated amount per claim).
• State the delivery format you prefer for benchmarking (examples: Excel with tabbed worksheets, PowerPoint summary, interactive dashboard). Options: Excel workbook, PowerPoint executive brief, Interactive dashboard, All of the above
• Identify acceptance criteria for the benchmarking deliverable (examples: required peer slices present, source columns matched to our fields, sample sizes documented).

Design Optimized Plan Options with Cost/Benefit Tradeoffs

• List the plan design levers you want analyzed (examples: increase deductible, introduce narrow network, add copay accumulator, carve out specialty pharmacy). Options: Deductible changes, Network tiering/narrow network, Pharmacy plan design, Cost-sharing structure, Other
• Which hiring and retention thresholds must plan designs preserve (examples: maximum employee contribution as % of pay, required dependent coverage levels)?
• Specify the employee contribution scenarios to model (examples: employer funds 80% of premium, fixed employee contribution tiers, graded contribution by salary band). Options: Fixed dollar contribution, Percentage of premium, Tiered contributions by salary band, Custom
• Identify any vendor or contract constraints that limit design changes (examples: current wellness vendor tied to incentives, active COBRA administration contract).
• Describe the employee communications or open enrollment timing considerations that would impact implementing a design change before renewal.
• Estimate the acceptable tradeoff threshold between cost reduction and benefit richness (example: maximum 5 percentage point reduction in covered benefits index).
• Which acceptance criteria will confirm a proposed plan design is approved for negotiation (examples: CFO sign-off on modeled PMPM, HR approval of employee contribution changes)?

Build Actuarial Pricing Models for Proposed Designs

• Provide the projection period required for actuarial pricing (examples: 12-month renewal, 24 months for multi-year forecasting). Options: 12 months, 24 months, 36 months
• Identify the rate cells and demographic splits you need modeled (examples: age bands, geographic rating areas, hourly vs salaried).
• Specify whether you require stop-loss attachment point scenarios included in the actuarial model and name the attachment points to test. Options: Yes, include stop-loss scenarios, No stop-loss scenarios needed
• Indicate the level of granularity for unit-cost assumptions (examples: per CPT code group, per DRG, per pharmacy therapeutic class). Options: CPT/Coding group level, DRG/group level, Therapeutic class for Rx, High-level per-claim averages
• Identify external assumptions we must use or avoid (examples: use industry trend 6% medical trend, exclude pandemic-year outliers).
• Describe the actuarial output formats you will accept for decision-making (examples: detailed scenario workbook, executive summary, model code or assumptions appendix). Options: Detailed Excel workbook, Executive summary slide deck, Both

Run Carrier RFP and Collect Competitive Bids

• Name the carrier markets or product types to include in the RFP (examples: national TPAs, regional carriers, level-funded products, PBMs).
• Specify mandatory RFP submission items you require from carriers (examples: network file, 12-month paid claims runout, sample contract redlines).
• Identify the competitive timeline constraints for issuing the RFP and receiving bids relative to your renewal date. Options: Standard 4-6 week RFP, Accelerated 2-3 week RFP, Custom timeline
• Indicate whether you require on-site presentations or remote bidder Q&A sessions as part of the RFP process. Options: On-site presentations, Remote Q&A, No presentations required
• State the minimum documentation you require to validate bidder pricing (examples: 834/EDI expected flows, sample rate cells, service-level commitments).
• Identify acceptance criteria for RFP completeness (examples: all bidders submitted network file and sample contract; bids include actuarial certification).

Negotiate Renewal Rates and Contract Terms with Carriers

• List the contract terms that must be negotiated beyond rate (examples: network guarantee metrics, stop-loss carveouts, prior authorization edits, data sharing cadence).
• Specify the non-financial KPIs you require carriers to commit to (examples: claim turnaround SLA, credentialing accuracy, network access percentages).
• Describe the signature authority required to finalize carrier contracts in your organization (examples: VP Total Rewards, CFO, board designee).
• Indicate whether you require fee-only disclosure and conflict-of-interest documentation to be attached to the contract packet. Options: Yes, attach fee-only disclosure, No, not required
• Specify any mandated contract language or clauses that must be included (examples: data use agreements, ERISA representations, indemnity limits).
• Identify measurable negotiation success criteria that will signal negotiation closure (examples: targeted renewal delta <= budgeted %, expanded network access by X providers).

Execute Pharmacy Carve‑Out Transition

• Which PBM transition elements must be included in scope (examples: rebate reconciliation process, formulary alignment, specialty drug migration plan)? Options: Rebate reconciliation, Formulary harmonization, Specialty migration, Clinical program migration
• Specify the cutover window you can support for PBM transition and any blackout dates (examples: do not transition during open enrollment or peak seasonal periods). Options: Immediate at renewal, 90-day transition window, Custom blackout dates
• Identify the required PBM integrations for your benefits platform (examples: real-time eligibility via 270/271, pharmacy claims feed, prior authorization interface).
• Describe employee-facing artifacts needed for PBM changes (examples: new formulary guide, specialty pharmacy letters, cost-savings FAQ).
• Estimate the volume of specialty scripts and high-cost members to be managed during transition (provide counts or tiers: 0-50, 51-200, 200+). Options: 0-50, 51-200, 200+
• Confirm whether you require interim financial reconciliation (examples: weekly rebate estimates during transition) and the frequency. Options: Weekly reconciliation, Monthly reconciliation, No interim reconciliation

Implement Reference‑Based Pricing Program

• Which provider categories will be in scope for reference-based pricing (examples: outpatient surgery, imaging, hospital inpatient DRGs)? Options: Hospital inpatient, Outpatient surgery, Imaging and diagnostics, All of the above
• Specify the reference basis you prefer (examples: Medicare plus X%, median allowed from benchmarking, state fee schedule). Options: Medicare + %, Benchmark median allowed, State fee schedule, Custom reference
• Identify the dispute resolution or balance-billing protection approach you require for members (examples: arbitration clause, provider outreach program, member advocacy hotline). Options: Member advocacy hotline, Provider negotiation support, Balance-billing protection language
• Describe the provider outreach and implementation tasks you expect (examples: provider education packets, claims repricing logic, pre-service estimate scripts).
• State the financial thresholds where reference-based pricing must escalate to full negotiation or carve-back (examples: claims > $50,000 bypass RBP). Options: >$50,000, >$100,000, Custom threshold
• Identify acceptance criteria for an RBP pilot before full roll-out (examples: member complaint rate <1%, average savings >10% on targeted categories).

Convert to Self‑Funded Plan and Place Stop‑Loss

• Specify the target stop-loss structure to model (examples: specific attachment $100k per member, aggregate attachment at 125% expected claims). Options: Specific attachment (per member), Aggregate attachment (plan level), Both
• Indicate the risk tolerance and capital considerations for moving to self-funded (examples: willing to retain up to $X of annual variance).
• Provide current stop-loss carrier details and policy end date if applicable (examples: carrier name, attachment, corridor, expiry).
• Identify the administrative tasks you expect us to handle for conversion (examples: premium conversion, COBRA administration transfer, ERISA publication updates). Options: Premium conversion, COBRA admin transfer, ERISA notices, Other
• Describe required actuarial deliverables for conversion acceptance (examples: employer liability projection, budget reserves, cashflow sensitivity analysis).
• Confirm the timeline and cashflow requirements for stop-loss placement (examples: binder by renewal, premium deposit schedule). Options: Binder by renewal, 30-day pre-renewal, Custom

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Fee-Only Compensation Disclosure
• Data Authorization & Release
• Data Processing Addendum (DPA)
• Project Leadership & Team Continuity Commitment
• Timeline & Milestones Schedule
• Payment Terms & Invoice Authorization
• Carrier Negotiation Agency Authorization
• Confidentiality & Non-Disclosure Agreement (NDA)

• Deliver final benchmarking report package
• Obtain written acceptance of benchmarking results
• Deliver negotiation outcomes package
• Obtain written acceptance of negotiation outcomes
• Deliver implementation artifacts
• Validate tested cutover and rollback plan
• Confirm named project leads and continuity commitments
• Complete acceptance criteria checklist mapped to Engagement Scope
• Receive billing authorization sign-off

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• 90-Day Realization & Incumbent Wind-down Review
• Quarterly Sustain & Improve Review

• Schedule the next quarterly sustain review and include the updated metric extracts five business days prior to the meeting.
• Confirm whether 90-day realized savings percent and in-network claim share percent meet or require remediation relative to Engagement Scope targets.
• Formally confirm the incumbent intermediary has been decommissioned or retained read-only and that contract and data archival steps are complete.
• Agree remediation tasks and timelines for any metrics not meeting expectations.
• Archive or terminate incumbent intermediary contracts and confirm read-only access or termination of systems within 14 calendar days to prevent parallel renewals.
• Deliver a remediation plan for any metric gaps identified at 90 days, including tasks and target resolution dates.
• Produce a short network-access report showing provider appointment availability and any clinic-level access concerns within 10 business days.
• YTD savings and clinical metrics review
• Confirm sustained progress toward year-to-date realized savings percent and preventive care compliance rate percent targets recorded in Engagement Scope.
• Prioritize the enhancement and issue backlog and agree delivery windows for the top three items.
• Confirm the shared channel and SLAs for issue resolution and escalation remain effective.
• Publish the prioritized list of enhancement requests with proposed delivery windows for the top three items within 7 business days.
• Update the shared issue channel with current SLAs and the escalation contact list.
• Re-confirm scope and owners
• Confirm claims and pharmacy feeds are flowing and parsed as expected for the go-live window.
• Identify and document any go-live blockers with a remediation task and resolution target.
• Confirm owners for each post-go-live checkpoint as recorded in Engagement Scope.
• Resolve identified data feed errors and reprocess affected claim batches within 7 business days.
• Publish a go-live exception register summarizing issues, temporary workarounds, and expected resolution dates.
• Enable reporting access for the Total Rewards and finance contacts and confirm a successful test report export.
• Produce an updated pharmacy spend PMPM breakout by therapeutic class and submit within 10 business days.
• Present first results against targets
• Determine whether realized medical cost savings percent and pharmacy PMPM are trending toward the Engagement Scope targets.
• Produce a short list of prioritized corrective tasks with resolution timelines.
• Agree the next data refresh schedule and report formats for ongoing monitoring.
• Run a claims-level variance analysis for the top three cost drivers and deliver the findings within 14 calendar days.
• Schedule the next sustain review and circulate the required data extracts to the review participants 5 business days prior.
• Present 90-day outcomes vs Engagement Scope targets
• Diagnose root causes for variances
• Incumbent intermediary wind-down confirmation
• Enhancement requests and issue backlog
• Deployment and data ingestion validation
• Agree corrective actions and timelines
• Network performance monitoring
• User access and reporting sanity checks
• Network and clinical outcome impact review
• Open issues, conditional remediation, and timeline
• Confirm timeline to ongoing cadence
• Operational SLAs and escalation path confirmation
• Early adoption and usage signals
• Open issues and immediate remediation actions