Outlier Clauses: Healthcare's Best Kept Secret | with Ryan Bojrab

"If you're expecting to pay $50k, but it hits an outlier clause, you could be paying upwards of three, four, five, six hundred thousand dollars." What if the single biggest driver of your high-cost claims isn't your discount, your network, or your utilization, but a contract provision almost nobody in this industry has ever read? My guest this week is Ryan Bojrab, who leads new solution development at Aon and came into this business through a channel almost nobody uses: he started his career as a clinician with a doctorate in physical therapy, treating patients inside a federally qualified health center. When carriers started dictating how many visits he could give a patient, he began pulling the thread, and hasn't stopped since. Ryan and I spend this episode discussing the outlier clause: the provision buried in hospital-carrier contracts that flips your negotiated discount once billed charges cross a threshold. Expecting a 50% discount on an open heart surgery? Once the trigger hits, you may be paying 70% of billed charges on the entire episode of care, and watching a $50,000 claim become a $500,000 one. Ryan calls it the casino's high roller table, and it's where hospitals make their money. It also produces one of the most perverse incentives in American healthcare: the longer you're in the bed, the worse your discount gets. If you've ever put two networks side by side, seen a massive pricing delta, and couldn't explain why - tune in. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: The Best Kept Secret in Network Contracts (00:05:59) From Clinician to Consultant: On the Receiving End of Every Vendor Pitch (00:10:46) Why Indiana Became a Self-Funding Powerhouse (00:16:00) What Is an Outlier Clause? The Casino's High Roller Table (00:21:00) The Hospital's Defense and the Inverted Discount (00:27:43) What You Can Actually Do: RFP Language and Direct Contracting (00:35:12) Prompt Pay Providers and the Death of Spec Advance (00:41:17) A Quarter-Million-Dollar Claim With No Checks and Balances (00:47:39) Decoupling Primary Care From Insurance (00:53:36) The Four Buckets of Quality (00:58:53) Tiering and Steering at National Scale (01:05:36) Closing Thoughts: Contract Terms Are the Next Frontier Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/