EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader
Relentless Health Value™April 18, 2024
40:0036.61 MB

EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader

For a full transcript of this episode, click here.

On the show today, I am going to use the term TPA (third-party administrator) and ASO (administrative services only) vendor kind of interchangeably here. But these are the entities that a plan sponsor—for example, a self-insured employer is a plan sponsor—but these plan sponsors will use to administer their plan. And one of the things that TPAs and ASOs administer is this so-called weekly claims wire.

Every week, self-funded employers get a weekly claims run charge so they can pay expenses related to their plan in weekly increments. The claims run usually comes with a register or an invoice. This invoice might be just kind of a total (“Hey, plan. Pay this amount.”). Or there might be a breakdown like, “Here’s your medical claims, and here’s your pharmacy claims.” Maybe there’s another level down from that of detail if the plan or their advisor is sophisticated enough and/or concerned enough about the fiduciary risk to dig in hard about what the charges are actually for.

I was talking about this topic earlier with Dana Erdfarb, who happens to be executive director of HR at a large financial services organization. Dana I’m definitely gonna credit for inspiring this conversation that I’m having today with Justin Leader. Dana was the first one to really bring to my attention just the level of hidden fees that are buried (many times) in these claims wires … because when I say buried in the claims wire, I mean not charged for via an administrative invoice. These hidden fees are also not called out in the ASO finance exhibit in the contract, by the way. So, yeah … hidden.

I don’t know … if you have to hide your charges, in my mind that’s a pretty big tell that your charges are worth hiding. Now the one thing I will point out is that just because the charges are worth hiding doesn’t necessarily mean that the services those charges are for are unwarranted. Some of these services are actually pretty worthwhile to do. There’s just a really big difference from a plan sponsor knowingly contracting at a known rate with a third party to do something versus paying for a service knowingly or unknowingly via fees hidden in a claims wire wherein the amount paid is not in the control of the one paying the bill.

Anyway, I was talking about all of this earlier, as I mentioned, with Dana Erdfarb. That conversation was exactly the framework that I needed to snag Justin Leader, my guest today, to come on the pod and really dig into the detail level of what’s going on with this claims wire. So, in this healthcare podcast, we’re gonna talk about the five fees that tend to be tucked in to many claims wires. We also talk about one bonus—not sure if it’s a fee—one bonus way that plan sponsors give money to vendors in ways the plan sponsor might be unaware of. Here are the five hidden fees that we talk about at length in the show today, and then I’ll cover the bonus:

1. Shared Savings Fees. This is where a member of a plan goes out of network, and the TPA/ASO goes and negotiates a discount from the out-of-network provider and then shares the savings. Get it? Shared savings? This category also might include BlueCard Access fees, which we talk about in the show. But there also could be overpayment recoupment fees lumped in here. This is where the TPA messes up, overpays, and then charges the plan sponsor a percentage of the money they just got back when they corrected their own mistake. I’m just gonna pause here while everyone contemplates how we’ve all gone so wrong in life to not have figured out a way to charge others when we correct our own mistakes. Here’s a link to a great LinkedIn post by Chris Deacon and a deep dive article on this topic.

2. Prior Auth Fees. Lots to unpack with this one, which Justin does in the pod.

3. Prepayment Integrity Fees. This is evaluation of the claim before it’s being paid. Listen to the show for how this may (or may not) differ from what the TPA/ASO is supposed to be doing (ie, it’s the TPA that’s supposed to be [yeah, right] adjudicating and paying claims).

4. Pay and Chase Fees. This is where a bill was paid wrong, and it’s not immediately the TPA/ASO’s mistake. This is where something like a provider double billed or overcharged or something, and the TPA/ASO later figures this out and then chases the pay to get the money back.

5. TPA Claims Review Fees. Sort of self-explanatory but also not. Again, please listen to the show for more.

When I’d been talking about all of this with Dana Erdfarb, as I mentioned earlier, just about this whole thing, she said something that Justin Leader echoes today: Many of these fees are structured as a percentage of savings. This is challenging for a plan sponsor because the savings is vendor reported and not validated. But it also means that if the savings increase annually with trend (as they, generally speaking, do), then the fees will increase with that trend as well—and that is something to keep in mind.

Okay … so, here’s the bonus thing that didn’t get a number in the show today, but it is certainly a way that plan sponsors pay money to vendors. And this is medical claims spread pricing. This is buried in the claims wire and inside the dollar amounts the plan sponsor thinks they are paying a provider for a service. It turns out that it can turn out that the amount the plan sponsor is paying is more than the check that’s being written to the provider for the service being delivered. Or the amount the plan sponsor is paying the provider for a service is more than for simply that service that has been rendered, right? The plan sponsor is paying the provider for other stuff as well, as is alleged in the DOL v BCBS of Minnesota lawsuit, which Justin brings up in the show today.

It drives me nuts, honestly, when there are people who tout their transparency. But then it turns out if the equation is A plus B equals C, only like one of the numbers is transparent. Sorry, functionally, that doesn’t count as transparency except in marketing copy.

This is all to say—and here’s Dana Erdfarb’s actionable advice which sums up points Justin also made—when employers review their medical plan vendor contracts, they should make sure to identify, review, and document all fees being paid to their vendors and incorporate this knowledge into their renewal/RFP (request for proposal) discussions and negotiations.

Jeff Hogan echoed this advice on LinkedIn the other day when he commented on this show: “Such a great opportunity for employers to have their administrative services agreements and other documents examined to discover these schemes. It’s not hard to do. Also, a great advertisement for the value of having retrospective audits performed. It is eye opening to see not only the amount of arbitrage but often how payers don’t even pay according to their contracts. Justin Leader is the perfect guest.”

As mentioned a myriad of times already, my guest today is Justin Leader, who is president and CEO of BenefitsDNA. Justin works with plan sponsors, both commercial plans as well as Taft-Hartley plans, across the United States.

Before we kick into the show today, I just want to thank By the 49ers for the really nice review on iTunes. By the 49ers calls Relentless Health Value a “leading voice in healthcare” and says he or she always leaves “with intrigue, a new idea or a new approach to problem solving.” Really appreciate that. That is certainly one of our goals around here. So, thank you so much.

Oh, also, please subscribe to the weekly email that goes out. You can do that by going over to our Web site and signing up. There are a lot of advantages to doing so, which I’ve talked about before, so I’m not gonna do so again; but it is a great way to make sure that if you’re a member of the Relentless Health Value Tribe, you are aware of the current goings-on.

You can learn more at benefitsdna.com or wefixyourhealthcare.com.

You can also follow Justin on LinkedIn.



Justin Leader began his career in the pharmaceutical and financial services industries. By 2011, Justin entered into the group benefits field consulting for many notable Fortune 500 clients.

In 2014, he established BenefitsDNA, an objective, independent health and welfare benefit plan consulting firm providing compliance oversight, actuarial services, cost mitigation, and traditional broker services to Group Health Plan Sponsors. As a Certified Health Rosetta Chartered Advisor (eighth advisor to join), he’s acknowledged for contributing to healthcare solutions in the United States both in policy as well as practice and is an avid supporter of Patient Rights Advocate.

Throughout his career, Justin has been instrumental in introducing successful healthcare benefit solutions to the market, which have been pivotal in solving critical issues and saving millions for employers and their employees.

As a mission-driven leader, he and his team are passionate about fixing healthcare one client, one member, and one partnership at a time. Having trademarked We Fix Your Healthcare, their mission is one that his team takes seriously.

Justin, a native of Bedford, Pennsylvania, holds a pre-medicine degree and a master’s degree in exercise science from California University of Pennsylvania. His dedication extends to servant leadership, volunteering in the local community including serving on the PA State Council of SHRM (Society for Human Resource Management) since 2016. Justin is a public speaker and owner of Leaders Never Quit, where he dedicates his time to inspiring others with a message of hope, humor, and resilience.


07:55 How is the claims wire typically explained to a plan sponsor?

11:18 What is the whole point of self-funding?

11:27 Why is it so vital to understand what you’re paying for?

12:38 What are the five “buried” items that wind up in these claims wires?

13:03 What is a shared savings fee?

17:10 “Rates are important, but so are your rights.”

21:01 What’s going on with prior auth fees?

23:35 What is prepayment integrity?

28:16 What is pay and chase?

31:54 What is a TPA claim review?

35:47 Is there medical claim spread pricing?


You can learn more at benefitsdna.com or wefixyourhealthcare.com.

You can also follow Justin on LinkedIn.


@JustinDLeader discusses #plansponsor #payments on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation


Recent past interviews:

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ASO,Employers,Fiduciary,Hidden fees,Savings,TPA,plan sponsors,