Payment Integrity for Captive Health Plans
Independent, full-lifecycle oversight—
pre-pay and post-pay & built for fiduciaries
Captive health plans sit at the crossroads of rising medical inflation, and growing fiduciary scrutiny under ERISA and the CAA. ClaimInformatics delivers conflict-free payment integrity that protects plan assets, improves member experience, and documents prudence, before and after dollars change hands.
The Challenge for Captive Health Plan Fiduciaries
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Captive health plans present opportunities but increase fiduciary duties. While self-funded models benefit both members and employers, overspending can erode their value. Many captives depend on TPAs and networks that can create conflicts of interest and lack transparency, obscuring costs.
Fiduciaries must understand that they remain liable for asset protection, as regulations such as ERISA and CAA state that accountability cannot be outsourced. Independent, conflict-free oversight is crucial for accurate claims processing and fulfilling fiduciary responsibilities.
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Conflict-Free Oversight: Payment integrity performed by a non-conflicted 3rd party.
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​Data Access: Full, timely access to raw claims data, no black boxes​
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Fee Transparency: No hidden fees or undisclosed compensation
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Fiduciary Documentation: Audit trails, defensible reviews, and benchmarking of prices.
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Why captives need independent payment integrity​
Your Fudiciary Partner
ClaimInformatics addresses this issue with the separation of powers: we conduct independent forensic reviews of claims and provide ERISA-aligned governance that prioritizes plan assets, not network politics.
?Why Claiminformatics
Full lifecycle payment integrity
(Pre-Pay + Post-Pay)
"Separation of powers in healthcare claims review is essential.
It's the proper way to uphold fiduciary responsibility."
Pre-Pay: Prevent waste before funds are released​
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100% forensic claim review—not sampling—using a proprietary rule engine that validates coding, medical necessity, and contractual terms before payment.
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SOC 2-certified, HIPAA-compliant controls and auditable trails designed for fiduciaries.
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Near real-time insights so issues are flagged and resolved before checks are cut—avoiding pay-and-chase.
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Member and Provider-Friendly Ajudication that pays accurate claims the first time, reducing member disruption, appeals, and provider frustration.​
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Pre-Payment Targets: 4–6% reduction in inappropriate spend
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Post-Pay: Continuous oversight and recovery​
ClaimInformatics' Ongoing Monitoring (OM) solution applies a monthly, 100% claims analysis to detect emerging issues, quantify overpayments, and document prudence, all with full transparency for plan fiduciaries. Our forensic post-pay work identifies errors, overcharges, and contractual discrepancies that result in measurable savings (typically between 1% and 4%), and includes recovery services to recapture improper payments.
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Our platform provides you with actionable insights right at your fingertips, enabling you to:
Spot high-cost members, high-cost providers, and leading procedures.
Identify overpayments and mistakes before they add up.
Facilitate recoveries and guarantee precise claim payments.
Oversee or assist in the recovery process.
Ensure compliance and accountability are maintained.
Independent Fiduciary Oversight for Captive Health Plans
Compliance: Adheres to ERISA and CAA requirements.
Risk Mitigation: Lowers the likelihood of facing penalties and legal issues.
Member Protection: Ensures the safety of plan assets while facilitating equitable reimbursement for providers.
Reduce Waste Eliminate improper payments, billing mistakes, and contract inconsistencies.
Enhance Fiduciary Protection: clear evidence of careful decision-making, openness, and adherence to regulations.
Enhance Cash Flow: Funds are not wasted, eliminating the need for future recovery.
Reduce Administrative Burden: Avoid lengthy recovery cycles and provider friction.
The Path Forward
Let’s Build Your Fiduciary Approach Together
ClaimInformatics is your go-to partner for fiduciary compliance and payment integrity. We complement—not compete with—your core claims operation.
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How to Start
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Schedule a fiduciary alignment consultation.
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Connect your claim workflow or TPA/Network platform
(Secure SFTP for EDI 834, 835, 837, CSV, and pipe-delimited files) -
Start delivering conflict-free claim oversight.
