Opus Inspection
2025 Health Plan Summary
Financial Performance Review
Executive Summary
The plan paid $9,793,064 in combined medical and pharmacy costs against mid-year re-projected costs of $9,570,507, demonstrating strong alignment with actuarial forecasting. While the organization experienced a modest deficit of $222,557 against projections, this outcome was influenced by a timing issue with prescription rebate distributions.
Most notably, Opus continues to significantly outperform market benchmarks. The organization's PEPM cost of $822.68 remains 30% below industry standards, representing approximately 2/3 of what comparable employers pay for health insurance coverage. This is primarily attributed to the specialized pricing program through LEA's Anthem product, which achieved a 79.9% discount compared to billed charges.
The plan faced challenges from concentrated high-cost claimants, with septicemia emerging as the leading cost driver at over $1.1 million across 11 members.
Separately, eight claimants exceeding $125,000 each represented 34% of total net claims on the 1000 plan, highlighting the significant impact of catastrophic cases on overall plan performance.
KEY TAKEAWAYS
- Net deficit of $222,557 driven by rx rebate timing
- 30% cost advantage versus market average
- $822.68 PEPM significantly below industry norms
- High claim concentration among top claimants
- Opus all-time PEPM in a value-based solution is $711.14.
- UHC PEPM equivalent is $1,267.45
- Kaiser Family Foundation PEPM for 2025 is $1,168.78
Financial Performance Overview
$9.57M
Reprojected Net Costs
Total net spend re-projected in July
$9.79M
Actual Net Costs
After all adjustments for rebates, reimbursements, and contributions
$223K
Initial Plan Deficit
Variance between actual net costs and reprojected amounts
The financial performance of the 2025 plan year was in alignment with the re-projections made in July despite run-out challenges. The re-projected costs estimated a total net spend of $9,570,507. Actual costs were $9,793,064, which represents the net amount after all adjustments for prescription drug rebates, stop-loss reimbursements, and employee contributions. This resulted in an initial deficit of $222,557.
However, this deficit requires contextual understanding. The plan received only three prescription rebate distributions during the plan year, when there are usually four quarterly distributions. This timing anomaly, attributed to administrative delays with CarelonRx, temporarily inflated the apparent deficit. Based on the average rebate amount of $187,314 observed across the three distributions received, the final net cost would have been approximately $9,605,750 with the fourth distribution included. This adjustment would reduce the deficit to $35,243, representing merely 0.37% of total costs and demonstrating statistical accuracy relative to original projections.
Market Comparison and Cost Advantage
Exceptional Market Performance
Opus Inspection's 2025 net per-employee-per-month (PEPM) cost of $822.68 represents remarkable value when benchmarked against industry standards. Had Opus maintained coverage with UHC or a comparable BUCA carrier with 8% annual increases, the projected PEPM would have reached $1,267.45— 1.54 x's of Opus' 2025 cost.
The Kaiser Family Foundation's 2025 annual survey of employee benefit plans establishes the national average net PEPM at $1,168.78. Opus Inspection's performance reflects a significant cost advantage compared to this benchmark, effectively paying 30% less than what the broader market pays for health insurance coverage.
Pricing Strategy Success Factors
LEA Partnership
Specialized pricing program through LEA's Anthem product delivers exceptional value
79.9% Discount Rate
Overall discount compared to billed charges significantly reduces claim costs
The primary driver of Opus Inspection's exceptional cost performance stems from the specialized pricing program negotiated through LEA's Anthem product. This strategic partnership has secured an overall discount of 79.9% compared to standard billed charges, representing one of the most favorable discount rates available in the current market. This pricing advantage applies across the full spectrum of medical services, from routine primary care visits to complex inpatient procedures and specialist consultations.
Large Claimant Analysis
Septicemia: Leading Cost Driver
Septicemia emerged as the single largest cost category, with a total spend of $1,099,092 affecting 11 members. This serious bloodstream infection required intensive hospital-based treatment, with the largest claimant incurring $704,870 in claims cost. In total, the 11 members experiencing septicemia accounted for 327 total inpatient days, reflecting the complexity and extended duration of treatment required for this life-threatening condition.
The concentration of septicemia cases highlights both the unpredictable nature of catastrophic health events and the critical importance of stop-loss coverage. These infections can develop rapidly from various underlying conditions and frequently require ICU-level care, aggressive antibiotic therapy, and extended recovery periods. The substantial cost impact underscores the value of proactive population health management and early intervention strategies to reduce infection risks.
Top Individual Claimants
1
Terminated EE (COBRA)
Total Incurred: $704,870.70
Sepsis treatment requiring extended hospitalization and intensive care management.
2
Employee
Total Incurred: $338,071.85
Malignant breast neoplasm treatment involving surgery, chemotherapy, radiation therapy, and ongoing oncology care.
3
Employee
Total Incurred: $236,902.10
Acute kidney failure requiring dialysis and intensive nephrology management. Renal failure represents both immediate treatment costs and potential long-term care needs.
4
Spouse
Total Incurred: $238,773.99
Antineoplastic immunotherapy for cancer treatment. Advanced immunotherapy represents cutting-edge cancer care with substantial pharmaceutical costs.
5
Child Dependent
Total Incurred: $216,920.63
Autistic disorder treatment including behavioral therapy, specialized services, and comprehensive developmental support programs.
Additional Cost Drivers and Utilization
Other Significant Conditions
Beyond septicemia and the top individual claimants, several other medical categories contributed meaningfully to overall plan costs. Central Nervous System conditions generated $77,028 in plan-paid claims, encompassing diagnoses such as stroke, seizure disorders, and neurological complications requiring specialized treatment. Coronary Artery Disease represented another significant driver at $78,185 in plan-paid costs, reflecting the prevalence of cardiovascular conditions requiring interventional cardiology, cardiac catheterization, and ongoing management.
The plan recorded 55 inpatient admissions, accumulating 547 total inpatient days. This utilization pattern reflects a relatively small number of members consuming intensive hospital-based care. The average length of stay per admission approximated 10 days, indicating complex cases requiring extended recovery periods rather than routine short-stay procedures.
CNS Conditions
$77,028 in plan-paid costs for neurological treatments
Coronary Artery Disease
$78,185 for cardiac interventions and management
Inpatient Utilization
55 admissions across 547 total hospital days
Next Steps and Ongoing Analysis
01
Data Aggregation
Additional clinical and claims data currently being retrieved from LEA for comprehensive analysis
02
Multi-Source Integration
Data must be aggregated from both Anthem and CarelonRx systems, requiring coordination across platforms
03
Complete Analysis
UBF will provide full analysis of 2025 plan year costs once all data sources are compiled
04
Strategic Planning
Insights will inform 2026 plan design decisions and risk management strategies
The analysis presented in this summary represents preliminary findings based on currently available data. Additional clinical and claims information is being retrieved from LEA to enable more comprehensive evaluation of cost drivers, utilization patterns, and opportunities for intervention. This supplemental data aggregation process may require several additional weeks as information must be compiled from multiple sources, including both Anthem's medical claims system and CarelonRx's pharmacy platform.
Once the complete dataset is received and validated, UBF will conduct a thorough analysis of all costs associated with the 2025 plan year. This deeper examination will identify specific opportunities for targeted interventions, evaluate the effectiveness of current utilization management strategies, and provide actionable recommendations for the 2026 plan year. Understanding the clinical details behind high-cost claims enables more sophisticated approaches to population health management, provider network optimization, and benefit plan design that can help moderate future cost trends while maintaining quality care access.
Notation to Reporting
Beginning Q1 2026, UBF will be transitioning to a new reporting platform to enhance the oversight and strategic optimization of your value-based self-funded model. This transition will provide Opus with access to advanced, probability-driven analytics that offer deeper insight into how specific plan design tweaks or network adjustments directly impact your long-term financial performance.
By leveraging this new platform, we can more precisely model the relationship between your value-based initiatives and overall plan costs, helping you refine your stop-loss structure and manage claims reserves with unparalleled accuracy. This enhanced reporting is designed to reinforce the stability of your self-funded strategy, identifying new opportunities to capture savings while ensuring your plan remains perfectly aligned with Opus’s financial goals and risk tolerance.