A Complete, Flexible Solution for UR, CM, Wellness, DM, and Cost Containment
As the health benefits landscape grows increasingly complex and cost pressures continue to mount, Third Party Administrators (TPAs) face the dual challenge of controlling expenses while ensuring members receive quality care. According to the CMS National Health Expenditure projections, U.S. healthcare costs are expected to reach $6.8 trillion by 2030, driven by chronic disease and an aging population. ¹
TPAs who proactively manage utilization and member health stand to deliver far greater value to their clients. Self-funded employer groups seek financial predictability as well as healthier workforces. That is why more TPAs are partnering with Hines.
Founded by a Registered Nurse, Judy Hines, Hines has been a pioneer in managed care for over 38 years, offering TPAs a one-stop shop for Utilization Review (UR), Case Management (CM), Disease Management, Wellness Programs, and Cost Containment with provider sign-off. Unlike many, we also provide these best-in-class services à la carte, letting TPAs tailor programs to meet specific client needs.
Going Beyond Reference-Based Pricing: An Integrated Care Management Strategy
While reference-based pricing (RBP) remains a popular strategy to control costs by paying hospitals a percentage over Medicare rates, it has clear limits. It does not inherently address member health risks, chronic conditions, or care navigation, which are primary drivers of escalating claims. In fact, the CDC reports that 90% of the nation’s $4.1 trillion annual healthcare spend is attributable to people with chronic and mental health conditions. ² Without comprehensive care management, these costs simply shift — unmanaged members may avoid preventive care, delay seeking help, and require more expensive interventions.
That is where Hines stands apart. By combining:
- Utilization Review (UR): Ensuring medical necessity and appropriate care settings before services are rendered.
- Case Management (CM): Guiding members through complex medical situations, improving outcomes and reducing readmissions.
- Disease Management: Targeted interventions to manage diabetes, hypertension, heart disease, and more, lowering ER visits and inpatient admissions.
- Wellness: Proactive engagement that helps at-risk populations stay healthier, reducing long-term claims costs.
- Cost Containment: Cost-basis Negotiations with a provider sign-off to secure appropriate savings for IN and OON claims.
TPAs can move beyond RBP to a holistic model that optimizes both member health and plan savings.
Flexibility to Meet Your Clients’ Needs: Complete or À La Carte Solutions
Whether you are a large TPA managing thousands of lives across multiple states, or a regional administrator with specialized employer groups, Hines adapts to your needs.
- Need only CM or DM? We integrate seamlessly with your existing partners.
- Want a turnkey program? We deliver the full suite, under one accountable partner, reducing administrative burden and ensuring data flows cleanly across all services.
This flexibility means your clients get exactly what they need — no more, no less — all supported by our decades of clinical expertise and powerful analytics.
Proven Impact on Member Health and Employer Costs
Why is this so critical for TPAs? Because effective care management directly correlates to reduced healthcare spending and improved workforce productivity.
- A meta-analysis published in Health Affairs found that disease management programs for conditions like diabetes and heart failure reduced hospital admissions by 12% to 30%. ³
- Studies show every $1 invested in Wellness returns $1.50 to $3 in savings via reduced absenteeism and healthcare costs. ⁴
- Targeted Case Management has been shown to cut avoidable hospitalizations by up to 40%, significantly lowering large claims. ⁵
Meanwhile, poor care coordination costs the U.S. an estimated $27.2 billion annually in preventable re-admissions. ⁶ TPAs that proactively manage care dramatically reduce these exposures for their self-funded clients.
Why TPAs Choose Hines:
✔ Founded by a nurse, focused on patients first.
✔ 30+ years of experience serving TPAs and self-funded plans.
✔ A single point of accountability for fully modular solutions.
✔ National reach with local sensitivity.
✔ Data-driven insights and transparent reporting.
✔ Clinical teams who understand how to navigate today’s fragmented healthcare system.
Meet Us at HCAA TPA Summit ’25 in Dallas
Hines is a proud sponsor of the HCAA TPA Summit 2025 in Dallas, Texas. Do not miss the opportunity to explore how Hines can transform your portfolio of care management solutions. Whether you are considering bundling UR, CM, Disease Management, Wellness, and Negotiations for a unified strategy — or you need to fill a specific gap with a la carte approach — we are here to help you deliver unmatched value to your clients.
Contact us today to schedule a meeting with a member of our sales and accounts management team. Let us discuss how Hines can help you deliver greater quality of care with more savings.
Ready to Learn More?
Call us at 800.735.1200 or email sales@hinesassoc.com.
We look forward to seeing you in Dallas!
Please stop by Table #20 to meet our team!
References
- CMS, National Health Expenditure Projections 2021-2030.
- CDC, “Health and Economic Costs of Chronic Diseases,” 2022.
- Mattke et al., Health Affairs, “Meta-Analysis: Disease Management Impact on Costs and Utilization,” 2018.
- Harvard Business Review, “What’s the Hard Return on Employee Wellness Programs?” 2010.
- Agency for Healthcare Research and Quality, “Preventable Hospitalizations,” 2020.
- Milliman, “The High Cost of Poor Care Coordination,” 2019.
