Unmasking the Hidden Costs: 5 Eye-Opening Truths About Managing Healthcare Expenses

Are you tired of watching healthcare costs spiral out of control with no end in sight? If you’ve ever thought the system was stacked against you, you’re right—it is.

On the latest episode of the Broken Healthcare Podcast, I sat down with Scott Fuqua , a veteran in the healthcare industry and VP at Advanced Medical Pricing Solutions (AMPS). Scott has spent over 20 years helping employers cut through the noise, exposing the tricks driving up costs, and sharing real solutions for managing healthcare expenses.

Here are 5 critical lessons from our conversation that you can’t afford to ignore:

1. The System Isn't Broken—It's Rigged

Let’s cut to the chase: the U.S. healthcare system is designed to make insurance carriers, pharmacy benefit managers (PBMs), and brokers richer—not to save you money.

Scott explained how major players in the industry profit when healthcare costs rise. They’re not just passive observers—they’re active participants in a system that benefits from inefficiency and overcharging.

If that doesn’t sit well with you, you’re not alone. There’s a way to fight back, but it starts with understanding the game.

2. Claims Management: The Hidden Budget Killer

Here’s something that blew my mind: 91% of facility-based medical claims contain errors. From upcoding to bundling tricks, many of these errors are deliberate, designed to pad bills.

Through medical bill reviews, Scott and his team at AMPS routinely uncover overpayments—sometimes as much as 15% of an organization’s total healthcare spend. Imagine what that could mean for your bottom line.

If you’re not auditing claims, you’re leaving money on the table.

3. Pharmacy Costs Don’t Have to Break the Bank

While Scott’s expertise at AMPS focuses heavily on claims management, he also pointed out how pharmacy spending eats up a massive chunk of healthcare budgets. By moving away from traditional PBMs and partnering with independent ones, organizations can cut costs drastically.

Transparency and independent solutions work wonders in reducing healthcare waste.

4. Self-Funding Isn’t Enough Without Active Management

I hear it all the time: “We’re self-funded, so we’re in control.” But if you’re still relying on the big-name insurance carriers for your network and claims administration, you’re not as independent as you think.

Scott highlighted the importance of choosing independent third-party administrators (TPAs) and exploring alternatives like reference-based pricing. Taking control means more than just switching to self-funding—it’s about rethinking the entire structure of your plan.

5. Transparency Is the Foundation of Cost Control

New regulations, like the Consolidated Appropriations Act (CAA), give employers the power to demand transparency from their carriers. But as Scott and I discussed, most employers don’t realize the leverage they now have.

Here’s what you should ask your carrier:

• Will they let you audit claims for accuracy?
• Are they willing to disclose how they calculate PPO discounts?
• Would they agree to take on a co-fiduciary role in managing your plan?

If they hesitate, it’s time to explore new partnerships.

Employers Have More Power Than They Think

Healthcare might feel like an uncontrollable expense, but Scott’s insights prove that change is possible. By focusing on claims reviews, adopting independent solutions, and prioritizing transparency, employers can save big without sacrificing employee care.

The system might be rigged, but that doesn’t mean you have to play by its rules.

Ready to stop overpaying for healthcare? Tune into my full conversation with Scott Fuqua on the Broken Healthcare Podcast.

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Whether it’s managing healthcare costs, improving outcomes, or solving challenges unique to your organization, I’m here to help.

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