Our Services

A.J. Lester & Associates, Inc. helps self-insured employers reduce medical plan costs and problems by eliminating the PPO middleman. By negotiating direct "win-win" agreements between employers and medical providers, we create direct provider networks that the employer controls. In each case, the employer-owned network facilitates better access to providers; saves claim dollars; reduces service problems; and improves employee satisfaction.

Direct provider contracting allows you to offer managed care benefits to employees wherever they live, including those areas where your current HMO or PPO has limited networks or none at all. Because direct networks are developed according to the needs of your company, not some insurance carrier, you'll have the right medical providers where and when you need them.

If you have employees in outlying areas, your claims fund may be subject to full retail charges from medical providers who won't participate in commercial managed care networks. However, most doctors and hospitals in outlying areas will do business directly with local employers and agree to reduced or discounted fees. Wherever your company is paying full retail charges is a viable location for a direct network and substantial claims fund savings.

When your company owns the direct network, there are no monthly access fees. Managed care companies typically charge network access fees ranging from $6 to $10 or more per employee per month, plus other administrative fees. These recurring fees add substantially to the cost of providing managed care benefits year after year, and greatly mitigate any actual savings from the commercial networks.

Direct agreements fully disclose all contractual and financial terms to both parties. Managed care companies don't disclose their provider contracts to the employer, or their employer contracts to the provider. By keeping both sides uninformed and apart, the middleman obfuscates the viability of providers and employers doing business directly. Direct agreements encourage openness and are based upon mutual trust, knowledge of the facts, and the desire for a long-term business relationship.

Direct contracting generates immediate savings through agreements with doctors and hospitals who might not otherwise participate in commercial managed care networks. Medical providers often give employers better deals than commercial managed care companies because direct agreements are well-regarded as both valuable and in the providers' best interests.

Direct provider networks allow greater access to managed care benefits for more employees. That creates the opportunity for greater out-of-pocket savings on medical care. Because employees typically share in the cost of the health plan through deductibles and co-insurance, reducing provider charges through direct contracts not only saves the plan money, but also results in greater savings for employees.

Direct provider contracting creates the favorable perception of a network built around the actual needs the employees and their families, rather than the needs of a commercial managed care company. Employer ownership of the network also inspires greater respect for and responsible use of the network by employees. Fewer customer service problems and lower out-of-pocket costs go a long way toward keeping employees happy.

Direct contracting creates better community relations because physicians and employers share the same objectives of keeping people healthy and keeping claim dollars in the local economy. Commercial managed care companies have little vested interest in the community beyond whatever profits can be gained from it. By working directly with each other, providers and employers can better support their community and foster greater cooperation as business partners.

As health plan costs continue to surge, direct provider contracting is a valuable strategy for brokers, consultants, and third party administrators (TPAs) to recommend to clients for reducing costs and improving service. A.J. Lester & Associates, Inc. can develop direct networks in locations where commercial PPO networks are not fulfilling the clients' needs for access, savings, or service.

A.J. Lester has spent the past 17 years developing direct contracting strategies, methodologies, legal documents, reimbursement schedules, communication materials, network maintenance techniques, and a myriad of effective tools necessary for successful contracting. We've negotiated tens of thousands of provider agreements and have refined direct contracting into a highly effective and predictable process. By recommending A.J. Lester & Associates, Inc. as an outside resource to clients, brokers, consultants, and TPAs also avoid the perceived conflict of interest with existing PPO relationships.

We are generally introduced to the client by the broker, consultant, or TPA as an outside expert in the field of direct contracting. While we are paid directly by the client for developing the provider networks, we maintain an interface with the broker, consultant, or TPA to make certain the needs of all parties are being represented.

No. The direct contracting services we provide to clients of brokers, consultants, and TPAs have inherent value in terms of improving a client's benefits plan and, ultimately, strengthening that client relationship. A happier client, whose network needs are being fully met, is also easier to defend against competing brokers, consultants, TPAs, or managed care companies seeking to take over the business.

For general information, which can be easily communicated to clients, read "Everything You Always Needed to Know About Direct Managed Care Contracting" or visit our publications section. Or you can contact us directly by e-mail or phone, or by submitting our on-line form.

The cold, hard reality for doctors and hospitals is that commercial managed care companies still control the means by which medical providers do business with employers. In the process, providers have been forced to accept adversarial contracts, dwindling reimbursements, and greater practice restrictions. Cutting out the middleman and contracting directly with employers is a viable alternative that every medical provider should consider.

Review and evaluate existing marketing efforts to determine existing opportunities for direct contracting.

Analyze current managed care contract participation in HMOs, PPOs, and other third party payor networks.

Analyze contractual and reimbursement terms of current managed care contracts, assessing the value of each contract to provider.

Identify potential contractual and market obstacles to direct contracting. Recommend actions to overcome them.

Develop strategies and action plans for implementation of direct provider agreements and integrated marketing plans.

Instruct medical providers' staffs in the art of direct managed care contracting.

Develop boilerplate agreements for use in direct contracting.

Identify employer market and viable direct contracting candidates.

Analyze managed care agreements solicited by HMOs, PPOs, and other managed care vendors. Recommend proper course of action (accept, reject, negotiate, etc.).

Represent medical provider in actual negotiation with commercial managed care vendors. Note A.J. Lester & Associates, Inc. cannot represent medical providers in any negotiation directly with employers.