Fiduciaries need the people, process, and technology to ensure plan oversight. After nearly a decade of litigation, Aetna Life Insurance Company and OptumHealth Care Solutions have agreed to pay $8.4 million to settle allegations that they concealed administrative fees inside claims using so-called “dummy codes.” 🚩 Allegations Plaintiff Sandra Peters argued that Aetna and Optum: Directed providers to submit claims with “Administrative Add-On Services.” Masked Optum’s adminis

We’re proud to see PLANSPONSOR continuing to advance the fiduciary conversation for employer health plans. In a recent article, Fiduciary In A Box and Claiminformatics collaborated to help employers and their partners streamline fiduciary oversight and document compliance with the Consolidated Appropriations Act (CAA) of 2021. Fiduciary oversight is critical to ensure compliance with CAA ClaimInformatics, Inc. is honored to be recognized as a trusted partner in this effort. O

Without transparency and access to THEIR data, plan sponsors risk breaching fiduciary duty under ERISA and the CAA. The 2025 Pulse of the Purchaser Survey confirms what many of us already know: affordability threats are not easing. For the fifth straight year, employers rank drug prices, hospital costs, and high-cost claims as the top drivers of unsustainable healthcare spending For self-funded plans, these challenges bring heightened fiduciary obligations. According to the

On September 3, 2025, the U.S. Department of Health and Human Services unveiled a major enforcement initiative targeting practices that restrict patient access to their own electronic health information (EHI).

2020 was a landmark year in healthcare – and not just because of Covid-19. Over the last 18 months, multiple government agencies have sought to hold large insurers accountable in court for alleged wrongdoing. On March 26th, 2020, the Department of Justice sued Anthem in the Southern District of New York, alleging that Anthem up-coded diagnoses submitted to the government to increase their reimbursement rate for Medicare Part C plans. The lawsuit alleges that, in addition to h

Employers and employees alike have witnessed the consequences of making healthcare inaccessible. Yet, it seems the costs of health plans, hospital visits, treatment, and drugs are not taking a dive anytime soon. In just the last year, medical debt has grown to $140 billion nationwide, according to the American Medical Association. This is only bound to rise as healthcare costs continue their upward trajectory. The Centers for Medicare and Medicaid Services reported that in 19

To protect their networks and bottom lines, health insurers don’t aggressively pursue widespread fraud, making it easy for scammers. Then they pass the costs off to you. Like most of us, William Murphy dreads calling health insurance companies. They route him onto a rollercoaster of irrelevant voice menus, and when he finally reaches a human, it’s a customer service rep who has no idea what he’s talking about. Then it can take days to hear back, if anyone responds at all. The

Martand Bhatt's parents weren't sure he needed immediate medical care when the energetic toddler burned his hand on the kitchen stove one April morning. Dhaval Bhatt, Martand's father, said he'd been warned about emergency rooms in hospitals after he arrived in the U.S. from his native India. "People always told me to avoid the ER in America unless you are really dying," said Bhatt, a research scientist and pharmacologist at Washington University in St. Louis. But after seein

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

Georgia's insurance commissioner has fined Blue Cross Blue Shield $5 million for violations of state laws and agency rules and regulations, the commissioner's office said March 29. Below is the statement of the Insurance and Safety Fire Commissioner, John F. King - “As Georgia’s Insurance Commissioner, my number one priority is protecting Georgia consumers,” said Commissioner King. “To that end, after numerous complaints made to our office regarding the operations of Blue Cro

We’re excited to announce that Stephen Carrabba, our President and co-founder, was featured in the most recent edition of The Self Insurer Magazine in an article entitled, The Rebirth of Health Care Consumerism, eloquently written by Bruce Shutan. Among other obstacles in health care, the article comprehensively describes how physician practices, health systems, surgery centers and others are encouraged to over-bill, by high-priced consultants who promise that implementing ev

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