Third Party Administration

Enterprise Group Planning specializes in offering flexible, self-funded plans tailored to your financial and benefit needs. We work closely with you to design and customize a plan that fits.

We manage all aspects of your self-funded plans, including medical, ancillary, prescription drug, care management, and more. From enrollment to claims processing and personalized customer service, we’re your comprehensive solution, delivering seamless administration and an integrated member experience.

EGP can work with employers to manage HRA accounts that are fully owned and funded by the employer. HRAs can be paired with a HDHP and are used to pay for eligible out-of-pocket medical expenses. With an HRA employees are able to receive tax-free reimbursements of medical expenses such as premiums, deductibles, copays, and prescription costs. HRAs limit an employer’s financial exposure while offering employees a way to reduce their healthcare costs.

We maintain enrollment and eligibility, and are able to manage varying eligibility rules. Managing eligibility doesn’t need to be complicated, employers are easily able to update an employee’s eligibility status and make changes for new hires or terminations throughout the year.

Enrollment can be done online and features comparison tools in a secure and HIPAA compliant.

We want you to be able to design the benefits that your business needs without having to compromise. EGP promotes fully custom plan designs and produces compliant plan documents and supportive documents and user-friendly employee communications.

Member Portal

Manage your health care with the online member portal where all your care information is in one simple place. Click here to learn more.

Mobile App

zConnect, a mobile app that helps simplify your healthcare and maximize benefits. This easy-to-use mobile app uses modern technologies to deliver personalized insights to understand your healthcare and improve your wellbeing. 

This value-added service provided by EGP, is unrivaled and supported by decades of experienced professionals providing consultative services which protect the interests of employer-sponsored benefit plans and the plan participants.

With EGP, clients get more than just transaction managers– our team provides custom risk management services supported by detailed reporting and analytics.

Our experts can identify unique risk conditions and secure clinical resources to manage and direct appropriate care. In addition, we provide access to specialty providers at negotiated rates and utilize claim analytic data to make recommendations for patient education and appropriate sources of care. Plus, we offer eligibility risk management and the application of alternative sources of coverage.

Case example #1

A newly diagnosed patient was administered an infusion therapy drug scheduled to be administered every six months thereafter. Billed charges of $143K were payable at a net rate of $62K after the application of the network discount. Our team, working with specialty drug sources and a clinical Case Manager to support the patient, executed delivery of the infusion therapy medication to the administrating provider rather than sourcing from the facility pharmacy.

As a result, the new billed charge amount for the second and subsequent treatments was reduced to $31.6K, and the net payable was reduced to $21.5K. A claim cost savings of $40,630.57 – every six months.

Case example #2

A pediatric patient required a specialty procedure. In cooperation with parents, a clinical Case Manager and third-party medical director identified a less invasive procedure available at a specialty hospital. Although still experimental, the specialty provider had a record of successful clinical trials. As a result, we negotiated a flat case rate with the facility at a rate lower than the traditional procedure. In addition, the facility agreed to assume any expenses in excess of the flat rate. Cost was 55% of the standard procedure cost while the patient benefited from quicker recovery based on the less invasive nature of the procedure.

Case example #3

Plan participant diagnosed with the need for organ transplant services. Our consultative team arranged for specialty review at an alternative facility with higher positive outcome data. Upon confirmation of diagnosis, the patient preferred to utilize the second opinion source, and our
team negotiated a flat case rate for the procedure. The negotiated rate allowed the patient to receive care from a provider with higher clinical outcome ratings without increasing the cost to the Plan.

EGP has developed relationships with stop-loss underwriters to provide secure excess loss coverage options for our customers which are offered on a fully transparent basis.

Essential administrative services and ancillary benefit administration are available to provide a comprehensive package of plan administration.

Dental & Vision benefit self-funded program administration is provided as well as access to dental network programs and fully insured options.

EGP can work with your pharmacy benefit manager (PBM) of choice to administer your prescription drug benefits. We are also able to help you select a prescription drug program that offers flexible plan design, specialty drug cost containment, attractive pricing, and access to a broad network of retail pharmacies.

As experts in health benefit management, we offer all of our customers personalized service to help them customize their plan. From plan design to implementation, we can offer our services through the entire process. Working with us, you get a dedicated account manager and US-based customer service. Each customer health plan is also assigned to a dedicated claim adjuster who is accessible to all plan participants. We are here whenever you need us, and your needs come first.

EGP is a leader in healthcare reimbursement management, offering innovative solutions that range from traditional PPO network access to customized direct provider contracts.

National and regional carrier networks and independent network options:

National and regional carrier networks, along with independent network options, offer providers contracted under proprietary terms between the network and providers. These networks typically ensure a wide selection of providers, guaranteed access, and acceptance of contract payments.

Defined payment plan:

Utilizing Reference-Based Pricing principles, including direct provider contracting, this plan reimburses non-contracted providers based on a factor of the Medicare fee schedule. Reimbursement levels are fully transparent to the Plan Sponsor, ensuring clarity and control.

We are able to administer healthcare and dependent care FSAs. Both options allow your employees to pay for qualified expenses on a pre-tax basis. Employees with an FSA will have a debit card that gives them a quick and easy way to access their funds and the ability to digitally submit claims.