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

Jun 5, 2025

38:49

Episode Description

Five Hidden Fees in Your Claims Wire That May Be Costing Your Plan Millions

The weekly claims wire looks like a payment for medical and pharmacy claims. But tucked inside that same wire, invisible to most plan sponsors, are fees that have nothing to do with the care your members received. One multi-employer fund reduced its $13 million in annual spend by $1.5 million just by getting better eyes on what was flowing through. Another plan's network-approved auditor found $21,000 in errors — and charged $25,000 to find them. An independent auditor then found more than 20 times that amount.

In this Take Two episode, Stacey Richter revisits her conversation with Justin Leader, President and CEO of BenefitsDNA, about the five fees buried in TPA claims wires that most self-funded plan sponsors are paying without knowing it — and what to do about it.

WHAT YOU'LL LEARN ✅ Shared savings fees: what plan sponsors are actually paying when a TPA negotiates an out-of-network discount, accesses a Blue Card network, or recovers an overpayment it made — including the perverse situation where a TPA can charge a fee to correct its own billing mistake, with some contracts allowing fees as high as 50% of "savings" against an undefined baseline

✅ Prior authorization fees: why charging a plan sponsor a separate fee to conduct prior authorization may amount to charging for doing the job the admin was already hired to do — and why delayed or denied prior auths can generate more fee revenue than approvals

✅ Prepayment integrity fees: 85 to 90% of claims are auto-adjudicated, and carriers sometimes agree in provider contracts not to review claims prepayment — meaning errors get let through intentionally or not, with more money made catching them post-payment than preventing them up front

✅ Pay and chase fees: when a provider overbills and the TPA goes back to recover the overpaid amount, the plan gets charged a percentage of the recovered dollars — on top of whatever the TPA already charged to adjudicate the claim incorrectly

✅ TPA adjudication itself: how auto-adjudication software checks eligibility, prior auth, and plan design without human review — and why "we pay claims accurately and timely" is a near-meaningless guarantee if you can't define what a clean claim is or access the data to verify it

✅ Medical spread pricing as a bonus category: the DOL v. BCBS of Minnesota lawsuit and the concept that what a plan sponsor pays for a service may exceed what the provider actually receives — with the difference flowing somewhere else entirely

WHY THIS MATTERS Julie Selesnick has said it plainly: it is the very definition of a fiduciary breach to have the same entity auditing claims also processing them. Getting gag clause language out of your contracts is a useless exercise, as Karen Handorf puts it, if you don't look at the data to figure out how it's hurting the plan and its participants. For self-funded employers, this episode is a field guide to asking the right questions of your TPA — and understanding why the answers have been so hard to get.

=== LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Take2-EP433

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0:00 Introduction

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?