EP285: The Fascinating Story of Billions of Dollars Going Missing When the Back Office Pays Health Care Bills, With Dawn Cornelis, Cofounder and Director of Transparency at ClaimInformatics

In this Episode 285, Stacey Richter talks with Dawn Cornelis, cofounder and chief transparency officer at ClaimInformatics, about the billions of dollars going missing when the back office pays health care bills.

WHAT YOU'LL LEARN

✅ Why third-party bill payers who claim to review every claim still miss double-digit percentages in savings

✅ The difference between fraud, waste, and abuse — and why that distinction matters

✅ Why carriers don't always push for better systems to catch inappropriate payments

✅ How unbundling and weak enforcement let illegal billing slip through

✅ What it actually takes to identify and eliminate fraud in claims data

WHY THIS MATTERS

Dawn Cornelis has spent 25 years auditing health care claims, and her experience suggests that when a third party specializing in bill payment says they've reviewed everything, that review often still misses a lot — ClaimInformatics regularly finds double-digit savings when they take a second look. With estimates putting total fraud, waste, and abuse in US health care at around a trillion dollars, this isn't a story about finding change in the couch cushions; it's a story about systemic gaps in how claims get reviewed and paid, and about carriers who don't always have the incentive to close those gaps themselves.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

🔗 Healthcare Industry Acronyms and Terms

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

02:54 The story in the data.

03:32 Who's submitting these claims?

04:10 The three problems with the data.

07:19 The varying factor between carrier systems to stop fraud, waste, and abuse.

07:59 Why carriers don't push for better systems to stop inappropriate dollars.

10:07 The difference between fraud, waste, and abuse.

11:46 "When it becomes the norm, that's what's very bothering."

12:13 The barriers or hurdles in the marketplace.

15:35 What we don't know about but could do better at when looking at the data.

18:01 "It's not so much the health system and what they are charging. It's about … what the contracted rate is agreed to. That's what drives our costs."

19:02 "Data's fixed for itself."

22:09 Identifying and eliminating fraud.

22:14 Unbundling and the lack of enforcement behind preventing illegal billing.

28:59 How providers ensure they aren't inadvertently harming employers and patients through billing.