Companies are continually faced with financial and operational risks attributable to health care benefit decisions.  The trend for the business community to increase their involvement in health care benefit decisions is related to the increases in medical expenditures, administrative and regulatory compliance, a sluggish economic recovery, lower operating margins and an aging workforce.  Healthcare providers are establishing accountable care organizations to coordinate the delivery of health care services to patients.  Employers and their employees seek economic opportunities and innovative technologies to obtain the most affordable, quality healthcare services without location constraints. The concept of the medical exchange program fulfills this corporate philosophy by establishing reliable referral services to health plan participants.  Prior research has not examined administrative, regulatory and fiduciary compliance risks associated with intrabound channeling of healthcare services within the United States. To address this gap in the literature, this paper will examine the design trends, special incentives that insurers and self-funded plans offer their enrolled subscribers, out of network considerations, and access to high acuity services.