Encore! EP285: Who Is Auditing These Healthcare Bills? Also, That Cigna Lawsuit, With Dawn Cornelis, Cofounder and Director of Transparency at ClaimInformatics

Who Is Auditing These Healthcare Bills? Also, That Cigna Lawsuit, With Dawn Cornelis, Cofounder and Director of Transparency at ClaimInformatics (Encore! EP285)

In this Encore, prompted by a Cigna class-action lawsuit alleging fraudulent lab billing, Stacey Richter revisits her conversation with Dawn Cornelis, cofounder of ClaimInformatics, about the roughly 30% of healthcare claims spending that's some combination of fraud, waste, and abuse.

WHAT YOU'LL LEARN

✅ The details of the Cigna lawsuit alleging a pseudonym lab entity was used to inflate a member's out-of-pocket costs

✅ The three main categories of claims problems: paid incorrectly, missed opportunities to help members, and claims that shouldn't have been submitted at all

✅ Why 5% to 10% of claims simply aren't paid correctly, according to Dawn's audit work

✅ Why some audit and recovery firms also do revenue optimization work for providers — the same providers whose claims they're supposed to be auditing

✅ Why plan sponsors need to ask who is auditing their claims data, and by whom

WHY THIS MATTERS

The Cigna lawsuit is a headline-grabbing example of a much bigger, quieter problem: roughly 30% of healthcare spending is fraud, waste, or abuse, and plan sponsors often don't know whether their claims are being audited by a firm with a conflicting revenue-optimization relationship with the very providers submitting those claims. Asking who's auditing the bills — and whether that auditor has skin in the other side of the game — is a basic fiduciary question too many plan sponsors haven't asked.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

06:57 The story in the data.

07:33 Who's submitting these claims?

08:04 The three problems with the data.

10:54 The varying factor between carrier systems to stop fraud, waste, and abuse.

11:32 Why carriers don't push for better systems to stop inappropriate dollars.

13:28 The difference between fraud, waste, and abuse.

14:46 "When it becomes the norm, that's what's very bothering."

15:10 The barriers or hurdles in the marketplace.

17:38 What we don't know about but could do better at when looking at the data.

19:10 "It's not so much the health system and what they are charging. It's about…what the contracted rate is agreed to."

20:04 "Data's fixed for itself."

22:49 Identifying and eliminating fraud.

22:54 The lack of enforcement behind preventing illegal billing.

26:01 How providers ensure they aren't inadvertently harming employers and patients through billing.