INDUSTRY PERSPECTIVES

Looking Back and Looking Forward

By Ben Krambeck, CEO

I really look forward to writing this article each year. Who you trust your health plan with is a huge decision, and I feel I owe you information. It was a massive year for ClaimDOC and the reference-based pricing industry in 2025 and here is what tops our list:

  • Growing industrywide momentum and support for nontraditional solutions
  • ClaimDOC shut down new sales
  • Pave the Way® continues to change the market

The Search for a Good TPA – Part 2

Selecting the right vendors for a reference-based pricing health plan isn’t an exact science. At the end of the day, it often comes down to experience, discernment, and the ability to read the signals vendors give off long before the contract is signed.

 

In this episode of ClaimTalk, Emma Fox joins Danielle Young, Bruce Hansen and Stephanie Mohr to continue their unapologetically candid examination of vendor dynamics to offer pointed insights on evaluating partners that can make or break a self-funded strategy. They break down what truly constitutes “good” and “bad” vendor vibes, define what real competency actually looks like, and outline how to identify red flags before they turn into costly mistakes.

 

If you’re serious about elevating your self-funded health plan performance, this conversation cuts through the noise and shows you what to look for, because not every vendor deserves a seat at your table.

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AUDIT SPOTLIGHT

Burden of Healthcare Fraud and Abuse Impacts Everyone

By Cynthia Swanson, RN, CPC, CEMC, CHC, CMPA, Senior Audit Manager

Program integrity strategies focus on pricing and reimbursing the correct amount to legitimate providers and suppliers for covered services — reasonable and necessary services provided to eligible beneficiaries — while concurrently taking actions to eliminate fraud, abuse and waste.

 

In this Audit Spotlight, we focus on healthcare fraud and abuse, significant concerns that drain vital resources, undermine trust, inflate costs and impact patients and providers alike.


Myrtle Beach, South Carolina

Hospital Bill $298,889.50

A one-day hospital stay for the treatment of a heart attack and cardiac arrest.


Plan

Member

Traditional Network Plan

$146,017.05

Median Commercially Contracted Price

$29,203.41

Patient Responsibility

(20% Coinsurance)

DirectAccess+

$29,310.41

ClaimDOC Allowable

$5,862.08

Patient Responsibility

(20% Coinsurance)

Savings

$116,706.64

$23,341.33

To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings.

Service Shoutout

"From the moment she picked up the phone, Devlyn's follow-up has been relentless in a good way. I am confident we will get issues resolved with my primary care provider because she continues to keep me in the loop. In a world where customer service is becoming a lost art, she has been a breath of fresh air!"

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