Take Two: EP433: The Mystery of the Weekly Claims Wire, With Justin Leader

Relentless Health Value

Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs.

They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees.

The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary responsibility for self-funded employers. Additionally, Leader shares insights from a Health Affairs article and mentions ongoing legal cases that highlight the financial discrepancies in TPA practices.

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06:32 EP457 with Cynthia Fisher.

06:56 How is the claims wire typically explained to a plan sponsor?

10:49 What is the whole point of self-funding?

10:58 Why is it so vital to understand what you’re paying for?

11:53 What are the five “buried” items that wind up in these claims wires?

12:12 What is a shared savings fee?

16:14 “Rates are important, but so are your rights.”

20:13 What’s going on with prior auth fees?

22:44 What is prepayment integrity?

27:29 What is pay and chase?

28:46 EP428 with Julie Selesnick.

30:58 What is a TPA claim review?

33:21 EP285 with Dawn Cornelis.

34:16 EP379 with AJ Loiacono.

34:45 Is there medical claim spread pricing?