A court-unsealed expert report in Comau v. BCBSM exposed $8.1M unreconciled and $7.3M overpayments. What it reveals about every self-funded plan’s blind spot.

A landmark Blue Health Intelligence analysis quantifies AI-driven upcoding in employer plans. For self-funded fiduciaries, it is a direct hit to plan assets and a fiduciary wake-up call.

Most plan sponsors ask how much they will save. Their ERISA counsel should be asking whether the vendor's percentage-of-savings compensation creates a prohibited transaction under Section 406. Here is the legal argument, the Post-Pay contingency gap, and why a fixed per-claim fee model is structurally immune.

Cross-plan offsetting costs self-funded plans millions in hidden fees. Learn how bulk recovery practices create fiduciary risks and what sponsors can do.

For many plan sponsors, the word “audit” suggests penalties or after-the-fact corrections. In reality, independent claims reviews are about prevention, transparency, and protecting plan assets. Not punishment.

When claim administrators audit their own networks, conflicts arise. Independent payment integrity ensures ERISA and CAA compliance, protecting plan sponsors, members, and fiduciary accountability.

As renewal season approaches, fiduciaries should carefully review contract terms and challenge “mandatory” payment integrity programs that shift costs back onto plans. If you’re being asked to pay to fix what you’ve already paid for, the time to push back is NOW!

Florida Women's Care, one of the largest women’s health providers in the state, revealed troubling allegations of systematic overbilling and upcoding designed to pad private equity profits. These practices come at a steep cost to patients and health plans.

Code Creeping or Upcoding. It's all the same, and the damage this has to employer plans across the country far exceeds the impact on governmental programs. Take a look at the latest report from the Office of the Inspector General. Click here to see the full report. WHY THEY DID THIS STUDY Hospitals have long been essential providers in our healthcare system. Medicare payments reflect their importance: nearly one-fifth of all Medicare payments are for inpatient hospitalizati

Don’t be surprised if the U.S. Department of Health and Human Services extends the COVID-19 public health emergency in mid-July, givenealth emergency in mid-July, based on what government officials have said. If it ends, however, the news will be cushioned by a five-month extension of telehealth flexibilities created during the coronavirus pandemic. Congress granted that extension as part of the sweeping omnibus spending bill approved in March. Those accommodations will provi

High-dollar claims are a persistent challenge for payers; a comprehensive payment integrity strategy can help ensure these claims are accurate and necessary. Overall healthcare spending is slated to increase exponentially over the next few years, and private payers are expected to cover a large share of the bill. The Office of the Actuary at CMS estimates national healthcare spending to grow at an average annual rate of 5.4 percent through 2028. This outpaces the average proj

Although telehealth offers many benefits for patients, it introduces operational complexities for providers and creates legitimate concerns about fraud, waste, and abuse for payers. The United States spends an average of $3.8 trillion per year on healthcare. Some estimate that fraud, waste, and abuse (FWA) costs the nation at least $114 billion annually — representing more than 3% of overall healthcare spending. So, what can payers and providers do to reduce the massive amoun