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ClaimInformatics is the gold standard in fiduciary protection.

Self-Funded Health Plans
Your Fiduciary Risk Is Real and Growing

$74B
Personal Liability

Every year, self-funded health plan fiduciaries face $74 billion in personal liability -
a silent threat lurking in unchecked claims, hidden overpayments, and complex billings. 

Without rigorous oversight, plan assets and even your personal finances are exposed to costly errors, fraud, and regulatory penalties.

Fiduciary Compliance Through Payment Integrity

Protecting You from Fiduciary Risk

Value of ClaimInformatics

FOCUS™ - Fiduciary Oversight, Compliance & Utilization Safeguard

ClaimInformatics delivers unmatched fiduciary oversight through our proprietary FOCUS framework — ensuring compliance, transparency, and financial integrity. 
 

  • 100% claims reviewed against industry-standard rules and over 850 proprietary edits

  • Episode of Care™ logic to detect complex billing patterns and systemic errors

  • Unbiased, conflict-free verification ensuring no vendor influence

  • Recovery share - clients receive 50% of recovered funds

  • Ongoing Monitoring for early detection - stop errors before they escalate

  • Pre-Pay - Pre-payment claim edits and oversight 

At ClaimInformatics, we equip you with complete transparency and forensic-level accuracy to identify improper payments, protect plan assets, and fulfill your fiduciary duties under ERISA and the Consolidated Appropriations Act (CAA).

 

Don’t let hidden risks compromise your plan or your personal liability.

ClaimInformatics FOCUS
  • One to three-year historical claims analysis evaluating 100% of claims

  • Flags pricing errors, abuse, and systemic payment failures

  • Valuable diagnostic tool for uncovering past inefficiencies and assessing fiduciary oversight risks

  • Ensures compliance with ERISA,
    CAA, as well as plan documents

  • Identifies financial leakage and overpayment at the source

  • Creates a defensible audit trail and reinforces prudent plan oversight

  • Proactive, fiduciary-focused solution monitors claims monthly, ensuring compliance and early issue detection

  • Recovers identified overpayments

  • Fulfills fiduciary obligations by
    restoring plan assets

  • Included with PAIR and OM, client receives 50% of recovered funds

The Growing Fiduciary Risk You Can’t Ignore

  • Unseen Overpayments Drain Your Plan: Auto-adjudication prioritizes speed over accuracy, while TPAs and networks profit from undetected errors.

  • Complex Billing Masks Fraud and Abuse: Upcoding, hidden fees, and price gouging silently inflate costs, sometimes tens of thousands per provider annually.

  • Personal Liability Is Real: Under ERISA, fiduciaries can be held personally liable for losses caused by breaches of duty, which can put their homes, retirement savings, and careers at risk.

  • Regulatory Scrutiny Is Intensifying: The Department of Labor is ramping up enforcement, and recent lawsuits set precedents that increase fiduciary exposure.

Fiduciary Oversight

Why ClaimInformatics?

ClaimInformatics Steps
  • True Independence: No revenue from TPAs, networks, PBMs, or providers - your fiduciary interests come first

  • Enterprise-Grade Security: SOC 2-certified and HIPAA-compliant platform protects your sensitive data

  • Unmatched Claims Intelligence: Proprietary AI-derived algorithms coupled with our Episode of Care™ logic uncover what others miss

  • Fiduciary Duty Alignment: Supports duties of loyalty, prudence, monitoring, fee reasonableness, and plan document adherence

  • Transparent Recovery Model: You share 50% of recoveries with full reconciliation and provider notifications

  • Strategic Advantage for Brokers: Differentiate your services by offering clients measurable fiduciary protection and cost control

We Stand By Our Clients & They Stand By Us

“As an ERISA attorney, CPA, and healthcare consultant, I’ve seen organizations claim to deliver payment and cost reduction. ClaimInformatics stands out because they actually delivered on their promises. We highly recommend ClaimInformatics!”

Tony Sorrentino, Chief Compliance Officer, Silverstone Group

“CI’s payment integrity program has helped MLBF identify an extraordinarily large amount of overspending and inefficiency we would otherwise not have found. I’d recommend CI to any funds looking to root out overpayments or inefficiency in health benefit costs”

Lou Mandarini, Administrator, Massachusetts Laborers Benefit Fund

Who's Looking Out For Your Plan?

Without a strong independent partner, like ClaimInformatics, everyone profits from opacity except you and your members.
 

  • TPAs profit from increased claims volume

  • Networks collect fees for "negotiating" prices and "cost savings"

  • Providers use revenue optimization tactics

  • Auto-adjudication prioritizes speed over accuracy

Who's Looking Out For Your Plan

Your Real-Life Blind Spots

What You're Not Seeing Is Costing You

Upcoding Example

Inflating Service Complexity to Increase Reimbursement

ClaimInformatics Case Study Upcoding
ClaimInformatics Case Study Episode of Care

Episode of Care Logic Example

Reviewing claims holistically reveals clear errors

$38K Overpayment - $7.6K Paid By The Member

Example of Hidden Billings 

Employer group was unaware that their network was charging a "negotiation fee" for IN-NETWORK claims

ClaimInformatics Case Study Network Fees
Surprise Icon

$48,000In Hidden Fees

The Fiduciary Duties You Must Uphold

As a self-funded plan fiduciary, your obligation goes beyond simply managing plan assets — it means actively protecting those assets through data access, independent oversight, and compliance with ERISA and CAA requirements.

You can’t meet your fiduciary obligations without your claims data. Access isn’t optional — it’s a legal duty.

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Monitor vendors and payments for errors, hidden fees, and waste

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Verify fee reasonableness and enforce contract terms

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Safeguard participant data and protect plan assets

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Avoid conflicts of interest through independent review

Want to learn more about your responsibilities?

We’ve created a full guide to help you understand all 8 fiduciary duties in detail.

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