The pitch for a point solution is usually clean: a condition, a population, a clinical model, an outcome. The diligence problem is that the solution has to be plugged into three operations it does not control, and each one has its own way of quietly not working. I have been the TPA receiving these programs, the cost-containment vendor sitting next to them on the plan, and the person on the direct contracting side talking to the provider's billing office. This is what I would ask.
Will the plan actually cover it?
An employer saying yes in a sales meeting is a long way from a covered benefit. For a self-funded plan, coverage means the plan document is amended to include the service, the summary plan description reflects it, the TPA builds the benefit and a routing rule so the claim pays the way the contract says, and the stop-loss carrier accepts the amendment. Each of those is a separate decision by a separate party, and any of them can stall the program for a plan year.
Many solutions avoid this by charging a per-employee-per-month fee outside the plan. That is faster to sell and easier to cut. It is a line in the employer's vendor budget rather than a benefit members are entitled to, which means it competes with every other PEPM on the broker's spreadsheet at renewal. Ask the company what share of revenue is inside the plan as a covered benefit versus outside it as a vendor fee, and what the renewal rate is for each. They behave differently.
Also ask who the buyer really is. In this market it is usually the broker or consultant, and their support depends on whether the solution makes the renewal conversation easier or harder. A program that requires a plan amendment, a stop-loss endorsement, and a new eligibility feed makes it harder.
What does "integrated with the payer" mean?
When a point solution says it is integrated with a TPA or carrier, the usual reality is an eligibility file. That is the minimum required to know who is a member. It is not a connection to the plan. Real integration has at least three parts: eligibility that updates on the plan's cadence and handles terminations, a defined claims or encounter path so the plan can see the service as a paid line rather than a monthly invoice, and utilization and outcome data flowing back in a format the TPA and the broker can put in front of the employer.
Without the second and third parts, the plan is paying for something it cannot see. That is survivable during the honeymoon and fatal at the first renewal where the broker asks what the program did. Ask for the integration inventory by TPA and carrier: which have a live eligibility feed, which have claims routing, which get outcome reporting, and how many of those integrations were built once and are reused versus rebuilt per client.
Then ask the TPA. A TPA that has to hand-build a plan design and a manual routing rule for every group that adds the solution will steer its clients away from it, quietly, because the work lands on the TPA and the revenue does not.
How does it get paid, and does that create a claim?
If the solution's services are meant to pay as claims, someone has to submit them with the right codes to the right payer. If the solution bills the member's primary carrier by mistake, the claim denies or pays at the wrong rate. If it bills the employer directly, the plan never sees it. If it is a bundled or capitated arrangement, the TPA needs a way to represent that in the adjudication system, and many systems do not have one. Ask how a single episode of care flows from the member's appointment to a paid line on the plan's claims report, and who touches it along the way.
What breaks on the provider side?
This is the part investors skip, and it is where a large share of utilization dies. Every point solution that touches a physical provider depends on that provider's front desk and billing office doing something different for this member than for every other patient who walks in. They usually do not know the program exists.
The member's record in the practice's EHR carries whatever insurance information was entered at the last visit, often years old. The front desk verifies eligibility against the primary carrier card the member hands over, finds it active, and moves on. The referral coordinator sends the patient where they always send patients. The billing office, which may be an outsourced company two states away, submits the claim to the payer on file. At no point did anyone see a flag that said this member is in a program with a different payment path. The solution's utilization report shows a member who enrolled and never engaged. The plan sees a claim that paid under the regular benefit at the regular rate.
The front desk and the billing office in a practice frequently do not talk to each other. Instructions given to one do not reach the other. A program that depends on a card in the member's wallet, or a note in the chart, is depending on a communication path that does not exist in most practices.
Ask the company how it handles provider onboarding and what it does when a claim bypasses it. Ask for the share of expected episodes that actually surfaced through the program's payment path versus leaking to the regular benefit. If they do not measure leakage, they do not know their own utilization.
What should be in the data room?
Revenue split between in-plan covered benefit and outside-plan PEPM, with renewal rates for each.
Integration inventory by TPA and carrier: eligibility, claims routing, outcome reporting, and whether each was built once or per client.
Time from employer signature to first member served, broken out by the step that took longest (plan amendment, stop-loss, TPA build, eligibility feed).
A walk-through of one episode of care from appointment to paid claim, naming every party that touches it.
Provider onboarding process and the measured leakage rate: episodes that bypassed the program's payment path.
Broker and consultant concentration, and every employer that did not renew in three years with the reason recorded at the time.
A point solution with a strong clinical model and weak plumbing will show excellent pilot results and poor second-year retention. The plumbing is the diligence.