Lockton review urges Grain Valley R‑V to secure claims data, re-evaluate PBM and stop‑loss terms
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Summary
An independent Lockton review advised Grain Valley R‑V to obtain its own claims warehouse, target claim audits, re-examine PBM arrangements and consider repricing exercises to control rising pharmacy and medical-pharmacy costs. The district benefited from consortium stop‑loss coverage but should continue active negotiation and oversight.
An independent benefits review presented to the Grain Valley R‑V School District board on Monday urged the district to secure independent access to its medical and pharmacy claims, tighten audit controls and re-evaluate pharmacy contract structures as costs shift toward specialty and medical-pharmacy treatments.
A Lockton consultant told the board the firm examined Grain Valley's contract with Cigna through the SIPGKC consortium and focused on medical, pharmacy and the district wellness center. The reviewer said the district currently carries a $300,000 stop‑loss attachment point and that while consortium membership has smoothed volatility and produced relatively modest renewals, the district should still examine the attachment level and stop‑loss arrangements relative to peers.
"You are the fiduciary of your plan," the presenter said, urging the district to demand claim files and not rely solely on carrier-supplied summaries. Lockton recommended procuring an independent claims data warehouse so the district can run repricing exercises and targeted audits, including prepayment reviews, rather than accept only carrier-selected audit samples.
The review also flagged pharmacy and PBM (pharmacy benefit manager) arrangements as an area of rising cost. The presenters described spread-pricing and incentive-driven shared-savings clauses that can leave plan sponsors with opaque margins, and recommended a formal PBM procurement process (RFP) or carve-out analysis to compare pass-through and traditional models.
Lockton highlighted medical-pharmacy events (J‑codes) and site-of-service optimization as increasing shares of total spend, and suggested considering biosimilars and narrower network options to reduce net costs. The consultants cautioned boards to scrutinize capitated behavioral-health fees and shared-savings language in contracts.
District leaders asked Lockton about next steps; the presenters said they could help design targeted claim repricing and audit scopes and noted follow-up work would be necessary to quantify savings. The board did not take action at the meeting; administration said it would consider the recommendations and discuss next steps with consortium partners.
What's next: administration will review Lockton's full report, consider a PBM RFP or repricing exercise and report back to the board; any contract changes or vendor procurements would return as future action items.