When a hospital looks at a direct case rate arrangement for the first time, the questions that settle it usually aren't the ones asked first. Here are four that do.

How is the price set, and who sets it? There's a real difference between a price negotiated case by case with the facility and a figure handed down from a schedule the facility had no part in writing. It's worth knowing which one is on the table before anything else gets discussed.

Who coordinates the patient? If the answer is the hospital, same as always, then what's on offer is a pricing agreement and not much more. A care navigator who owns the episode from referral through recovery is a different proposition, and it changes what the hospital's own staff have to carry.

When does payment arrive, and in what form? Ask whether the facility is paid directly, at the amount agreed, on a timeline written into the agreement. Then ask what the agreement says happens if that timeline slips.

What happens when a case turns out to be more complex than expected? Every planned case carries that possibility. The right moment to settle who absorbs it is before the case, in writing, not during it.

Direct Care Alliance answers all four in the first conversation. We'd rather a facility ask them at the start than find the answers mid case.

There's a fifth question sitting underneath the others, and it's the simplest one. Does the hospital know the number before the patient arrives? In this arrangement the answer is yes, because the employer has already agreed to it. No prior authorization is needed. The price is agreed in advance.

If you've evaluated one of these arrangements before, the question you wish you'd asked first is probably worth more to the next hospital than anything we could write here.

A hospital planning a surgery three weeks out knows a lot about it. Which room. Which team. How long the case should take. What supplies it'll use. What recovery looks like if it goes the way these cases usually go.

What the hospital doesn't know is when the money arrives, or how much of it.

That isn't a scheduling problem and it isn't a billing problem. It's a design problem. In the usual arrangement the price isn't settled until after the care has happened, so the one number the finance office needs most is the last number anyone produces. Everything downstream inherits the delay: the forecast, the staffing plan, the capital decision that was waiting on the forecast.

Direct Care Alliance starts at the other end. The price for the episode is agreed with the facility before the case is scheduled. The employer commits to that price in advance. The facility is paid directly, at that amount, on the timeline the agreement sets.

Nobody's chasing anything afterward, because there's nothing left to argue about. The case was priced, the payer agreed, the care happened, the payment followed. A lot of the work that normally happens after a case just doesn't need to happen.

For a hospital, a planned case becomes as forecastable financially as it already is clinically. The schedule and the ledger finally describe the same event.

This isn't the right shape for every case, and it isn't meant to be. It's built for planned specialty care, the episodes that show up on a calendar weeks before anyone sees a claim: spine and orthopedic surgery, cancer treatment, general surgery. Those are also the cases that drive what a self-funded plan spends, which is exactly why they're worth settling first.

By the time a benefits adviser sits down for a stop loss renewal, the year's already been decided. The cases that shape the number ran in March, in June, in August. The renewal meeting is a reading of them, not a negotiation over them.

That's worth saying plainly, because it changes when a plan can actually be influenced. A conversation in December is about what's already happened. A conversation in March is about what's still in front of the plan.

Planned specialty care is where this hits hardest. Spine and orthopedic surgery, cancer treatment, general surgery. These episodes carry a lot of what a self-funded plan spends, and they're also the ones that show up on a calendar weeks before anyone sees a claim. There's a window there that most plans never use.

Direct Care Alliance works inside that window. When a planned case is identified, the price for the whole episode is agreed with the facility before the care is scheduled. The employer agrees to that price up front. A navigator coordinates the episode from referral through recovery. There's no balance billing, so the patient doesn't get a bill afterward.

For an adviser, none of this changes the plan. The plan document, the deductible, enrollment and the member card all stay exactly as they are. What changes is that one category of case stops being something the plan finds out about after the fact.

The ask is small. When a planned specialty case comes up in the spring, it's worth one conversation before it's scheduled, instead of one conversation about it in December.

Direct Care Alliance works through benefits advisers and third party administrators. Employers are reached through their adviser, never around them.