I decided to take a second listen to this episode due to the large number of posts on LinkedIn and conversations by the likes of Peter Hayes, Jamie Greenleaf, Steve Ditto, Julie Selesnick, Chris Deacon, Darren Fogarty just about the dollars disappearing when TPAs (third-party administrators) managed to get themselves in the middle of dollars flowing between the first party and the second party.
For a full transcript of this episode, click here.
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And for the record here, I am conflating TPAs and ASOs (administrative services only) here—which may or may not be fair in some cases, but just FYI. I am also not digging into the whys and the wherefores and some of the constraints that TPAs may face from their carrier and PPO (preferred provider organization) network partners, etc.
But consider the RHV (Relentless Health Value) episode a couple of weeks ago with Ann Lewandowski (EP476), where we discussed a whistleblower case where the TPA arm of an EBC (employee benefit consultant) managed to pocket (allegedly) something like $27 million of their client’s money and put it in their executive bonus pool—$27 million!
Probably (and when I say probably, I mean definitely) in that whistleblower episode earlier, I didn’t make it fully clear that it was the TPA arm of the EBC, the broker, that was allegedly responsible for the money getting lost in the middle in a very not transparent way. And I thank Joe Levon for bringing this to my attention.
Joe wrote me, “I hope transparency wins.” Me, too, which is why transparently revealing the mystery of the weekly claims wire really matters. So, let me pivot to my guest for this take two about the claims wire today.
Justin Leader, who recently wrote a post on LinkedIn that goes like this: “TPAs, the hidden middlemen driving up healthcare costs. [Everybody’s] talking about PBMs [pharmacy benefit managers]—and for good reason. But TPAs? Still operating in the shadows.”
Then Justin mentions a Health Affairs Forefront article by Karen Handorf, Christine Monahan, and Kennah Watts. Justin writes, “This Health Affairs … article … uncovers the hidden fees, spread pricing, and conflicting incentives embedded in TPA [contracts] that too often leave self-funded employers in the dark and employees footing the bill.”
Then Justin continues, “And while you’re at it, check out my conversation with Stacey Richter on Relentless Health Value Podcast, where we explore this very topic: ‘The Mystery of the Weekly Claims Wire.’” So, right, here you are. Welcome to it.
Today you will get to hear my conversation with Justin, where we pull back the curtain on these opaque practices and get back to aligning incentives with the people who matter most: members and plan sponsors. So, let’s do this thing.
Oh, before we do, though, huge shout-out to Justin Leader, founder and CEO of BenefitsDNA for being named a finalist for Advisor of the Year by BenefitsPRO. Congrats, Justin! So well deserved.
Also mentioned in this episode are Peter Hayes, Jamie Greenleaf, Steve Ditto, Julie Selesnick, Chris Deacon, Darren Fogarty, Ann Lewandowski, Joe Levon, Karen Handorf, Christine Monahan, Kennah Watts, BenefitsDNA, BenefitsPRO, Cynthia Fisher, VerSan Consulting, Cora Opsahl, Al Lewis, Mark Davenport, Dawn Cornelis, AJ Loiacono, Mike Miele, and Patient Rights Advocate.
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.
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.
34:45 Is there medical claim spread pricing?
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Andreas Mang and Jon Camire (Part 1), Stacey Richter (EP477), Charles Green (Bonus Episode), Ann Lewandowski, Peter Hayes, Yashaswini Singh, Dr Kenny Cole, Dr Eric Bricker, Dr Christine Hale, Nikki King, James Gelfand (Part 2), James Gelfand (Part 1)