What Is Your Health Plan Really Paying? Stephen Carrabba Takes the PLANSPONSOR Stage to Demand Answers

Wednesday, April 15, 2026 · 2:00 – 3:00 PM ET · Free Livestream

Your TPA's dashboard shows you what was paid. It doesn't show you whether it was paid correctly.

Buried inside every claims feed is a story the numbers don't tell — diagnosis codes sequenced to bypass medical necessity edits, component procedures unbundled to multiply reimbursement, services billed under facility rates that were never delivered in a facility, and codes submitted that haven't been valid for years. None of it shows up in your carrier's dashboard. All of it is costing your plan money.

This Wednesday, that story gets told on a national stage.

Stephen Carrabba, Founder and CEO of ClaimInformatics, joins PLANSPONSOR's Roadmap 2026 Livestream Series as a featured speaker in Session 2: "Data-Driven Decisions — Let's talk payment integrity." The free livestream runs Wednesday, April 15, 2026, from 2:00 to 3:00 PM ET. This session is for plan sponsors who want to go beyond summary reports and start asking the questions carriers would prefer they didn't.

"Most plan sponsors are looking at the summary, not the claims. That's exactly what your TPA is counting on. The moment you actually look at the data — what was billed, what was paid, what your plan document says you should have paid — the gap between those numbers becomes your fiduciary obligation to close." — Stephen Carrabba, Founder & CEO, ClaimInformatics

What Wednesday's Session Covers — And Why It Matters Now

PLANSPONSOR's Health Benefit Fiduciary Duties series is one of the most widely attended compliance education programs in the self-funded benefits space. The 2026 series is specifically designed to arm plan sponsors with the tools and vocabulary to hold vendors accountable — an increasingly urgent mandate as ERISA enforcement intensifies and the Schlichter litigation playbook migrates from 401(k) plans into employer health benefits.

Session 2, featuring Carrabba, will walk attendees through three core disciplines every fiduciary needs:

• Turning raw claims data into actionable fiduciary intelligence. Plan sponsors will learn how to read their own data — not the curated dashboards carriers provide, but the actual claims-level information that reveals coding errors, medical necessity failures, and billing patterns inconsistent with plan documents.

• Understanding what your health plan is really paying. The session will expose the gap between negotiated rates and actual amounts paid, and show why that gap is not always attributable to legitimate repricing or discounting.

• Contract review and negotiation strategies. Attendees will receive practical guidance on ASO agreement provisions that restrict data access, limit independent review rights, and create conflicts of interest — along with specific language strategies to close those gaps at renewal.

These topics are not theoretical. On January 15, 2026, EBSA formally overhauled its FY 2026 national enforcement projects — explicitly prioritizing compliance with the No Surprises Act, service provider oversight, and the removal of barriers to participant benefits. Plan sponsors operating without independent claims oversight face exactly the kind of process gaps EBSA investigations are designed to expose. The session is also grounded in the CAA disclosures now required for every self-funded plan and in the pattern of ERISA litigation that has already produced significant settlements against major employers, brokers, and consultants.

The Data Access Problem Is a Fiduciary Problem

The premise of Wednesday's session is simple but uncomfortable: you cannot meet your fiduciary obligation to a self-funded health plan without full access to your own claims data. Yet the majority of plan sponsors operate without it.

Under Section 201 of the CAA 2021, group health plans are prohibited from entering into contracts with TPAs, carriers, or networks that restrict the plan's ability to electronically access de-identified claims and encounter data for each participant upon request. Contracts that limit that access — through gag clauses, delayed delivery timelines, redacted data feeds, or fees designed to discourage use — are in direct conflict with federal law.

More importantly, a plan sponsor who does not obtain and analyze that data has no basis for confirming:

• Whether claims were adjudicated correctly against the plan document

• Whether negotiated rates were applied as contracted

• Whether billing patterns reflect medically appropriate care or systemic upcoding

• Whether vendors' representations about payment integrity are accurate

• Whether the plan is receiving the full benefit of any recovery or shared savings programs

Without that data, every fiduciary decision rests on the carrier's own self-reporting. And carrier self-reporting is structurally incapable of being independent.

What Carriers Don't Show You in the Summary Report

Every TPA and carrier produces dashboards. They show paid amounts, top diagnosis codes, specialty utilization, and cost trends. What they rarely show — because they're not designed to — is whether those paid amounts were correct in the first place.

The ClaimIntelligence™ edit suite applies a library of a proprietary edit suite across 8 payment integrity categories, grounded in published CMS, AMA, and CDC rules, ICD-10 coding guidelines, CPT® conventions, and federal billing standards. As Stephen often puts it plainly: these aren't proprietary opinions — they're the industry's own rules for correct billing. When your plan doesn't enforce them, you pay more than any informed payer would accept.

Under ERISA, paying claims that violate published billing standards — without any process to detect or prevent such errors — is difficult to reconcile with the duty of prudence that the circumstances require.

The 8 edit categories the ClaimIntelligence™ suite enforces — coding accuracy, duplicate detection, provider validation, plan compliance, eligibility, pricing accuracy, fraud indicators, and coordination of benefits — apply across both pre-pay and post-pay review as two halves of one continuum. Every edit that fires creates a documented record that the plan reviewed the claim against published standards and took appropriate action. That documentation is the foundation of fiduciary defense.

"The question for every self-funded plan isn't whether these errors exist in their claims — industry data consistently shows 5–15% error rates across all payers. The question is whether anyone is looking."

What Contract Reviews Actually Catch — And Why Renewal Is the Moment

The second major focus of Wednesday's session is contract review. For most plan sponsors, the ASO agreement with their TPA is a document they signed once and haven't critically examined since. That's a liability — and in the current enforcement environment, it may be an ERISA violation.

ClaimInformatics' CLEAR™ review (Contract Language ERISA Analysis & Redline) is a comprehensive fiduciary compliance assessment that performs 100% contract language analysis across TPA/ASO agreements, Summary Plan Descriptions, PBM contracts, and stop-loss agreements — running 1,100+ compliance checks against ERISA §404, §406, and §408, the CAA, PHSA, and other relevant requirements, with specific redline corrections and regulatory citations delivered before you sign.

Unlike advisory consultants who offer strategic recommendations, CLEAR™ delivers actionable redline language, documented counter-arguments for TPA pushback, and a fiduciary paper trail ready for litigation defense — in hours, not weeks.

The CLEAR™ Review: 4-Step Process

• SUBMIT — ASO/ASA, SPD, PBM, and Stop-Loss contracts for review

• ANALYZE — 100% contract language reviewed for ERISA, CAA, PHSA, and other relevant violations

• REDLINE — Specific corrections with regulatory citations, ready for your counsel

• PROTECT — Documented prudent process for litigation defense and DOL readiness

Across hundreds of contract reviews, ClaimInformatics consistently finds four categories of high-risk provisions that plan sponsors never knew were there:

• Discretionary authority clauses — Language granting TPAs broad decision-making power that quietly shifts fiduciary liability away from the plan sponsor — and onto a party with no fiduciary obligation.

• Data access restrictions — Gag clauses and delivery limitations that prevent the plan from accessing its own claims data in usable form — in direct conflict with CAA §201 requirements.

• Fee opacity — Hidden fees, undisclosed revenue streams, and ambiguous compensation structures that make it impossible to assess whether vendor arrangements are reasonable under ERISA §408(b)(2).

• Punitive termination provisions — Excessive notice periods, data handoff restrictions, and financial penalties designed to make it prohibitively costly for a plan sponsor to exercise its right to change vendors.

Each of these represents a potential breach point — either because the clause itself is inconsistent with CAA or ERISA requirements, or because it prevents the plan sponsor from exercising independent oversight. A plan sponsor who signs without a CLEAR-level review has no documented basis to claim they have fulfilled the prudent expert standard.

The contract renewal window is the most powerful leverage point a plan sponsor has. Once the contract is signed, the ability to negotiate data access rights, review rights, and independent oversight provisions shrinks dramatically. Don't sign until you've seen what's hidden.

The ClaimInformatics Approach: Independent Oversight at Every Layer

ClaimInformatics is the only payment integrity partner in the market with no ownership, revenue sharing, or contractual relationships with TPAs, carriers, networks, or providers. That independence is not a marketing point — it's the technical requirement for conflict-free fiduciary oversight.

The ClaimIntelligence™ edit suite enforces the industry's own published rules — CMS, AMA CPT®, NCCI, ICD-10, and federal billing standards — across 100% of claims, not a statistical sample. Three things follow from that:

• Money stays in the plan. Each edit category represents a specific, documented type of billing error in which the plan pays more than the published rules require. These aren't negotiation points — they're math.

• Personal liability is addressed. Under ERISA, plan fiduciaries have a personal duty to ensure plan assets are spent prudently. Lacking a process to detect known billing errors — errors for which CMS publishes rules — is difficult to defend in a regulatory investigation or litigation.

• Prudence is documented. Every edit that fires creates a record that the plan reviewed the claim against published standards and took appropriate action. That documentation is the foundation of fiduciary defense.

Results across the ClaimInformatics client base confirm the pattern:

• Over $16B+ in claims analyzed across self-funded employers, Taft-Hartley funds, and captive programs

• 5–15% error detection rates on reviewed claims populations — consistent with industry-wide data

• $500–$1,200 per employee per year in average findings

• Audit-ready documentation on every edit and recovery, specifically designed to support DOL investigation and litigation defense

Both pre-pay and post-pay solutions are available as two halves of one continuum. Pre-pay editing applies the ClaimIntelligence™ edit library before plan funds are released — the highest standard of fiduciary protection, and one that eliminates the recovery burden for errors caught at the front end. Post-pay (including PAIR™ historical lookback) provides retroactive recovery and validation across 2-3 years of prior claims.

Frequently Asked Questions

What is payment integrity in a self-funded health plan? Payment integrity refers to the processes and controls that verify health claims are billed correctly, coded accurately, and paid in accordance with the plan document, network contracts, and applicable regulations. For self-funded plan sponsors, maintaining payment integrity is a fiduciary obligation under ERISA — not an optional service or vendor add-on.

What is the PLANSPONSOR Roadmap 2026 livestream, and how do I register? PLANSPONSOR's Roadmap Livestream Series is a multi-session compliance education program designed for plan sponsors and benefits advisers. Session 2, "Data-Driven Decisions — Let's talk payment integrity," features ClaimInformatics CEO Stephen Carrabba and airs Wednesday, April 15, 2026, at 2:00 PM ET. Registration is free at plansponsor.com.

Why can't I rely on my TPA's own payment integrity reporting? A TPA reviewing its own claims adjudication creates an inherent conflict of interest. The same organization that processed the claim is determining whether it was processed correctly, with no independent verification. ERISA's prudent expert standard requires that fiduciaries monitor service providers independently — meaning engaging a third party with no financial relationship to the TPA, carrier, or provider network.

What should I look for in my ASO agreement before the next renewal? Key provisions to review include: (1) data access rights — do you have the right to receive complete, claims-level data without additional fees or approval requirements? (2) independent review rights — can you engage a third-party payment integrity vendor without TPA approval? (3) recovery provisions — are overpayment recoveries returned to the plan in full, or does the TPA retain a portion? (4) gag clause prohibitions — does the contract comply with the CAA's prohibition on terms that restrict your ability to share data with business associates?

What does independent payment integrity oversight actually cost? ClaimInformatics operates on a success-based model for recovery services — no findings means no fee. Pre-pay and ongoing monitoring services use a per-employee-per-month pricing structure that, for most self-funded plans, is more than offset by identified savings within the first year. Average findings of $500–$1,200 per employee per year consistently demonstrate positive ROI across the full PEPM cost range.

What is a CLEAR™ review, and do I need one before renewal? The CLEAR™ review (Contract Language ERISA Analysis & Redline) is ClaimInformatics' independent contract analysis service covering TPA/ASO agreements, SPDs, PBM contracts, and stop-loss agreements. It performs 100% contract language analysis with 1,100+ compliance checks against ERISA, CAA, PHSA, and other relevant federal and state requirements, uses a 5-level risk severity classification, and delivers specific redline corrections with regulatory citations ready for your legal counsel. It also provides documented counter-arguments for anticipated TPA pushback. If your contract is coming up for renewal — or if you have never had an independent review — a CLEAR™ analysis before you sign is one of the most defensible steps a plan fiduciary can take.

Register for Wednesday's Livestream — Free

Join Stephen Carrabba and PLANSPONSOR on Wednesday, April 15, 2026, at 2:00 PM ET for a live session on turning health plan data into defensible fiduciary decisions.

Have a contract renewal coming up? Request a CLEAR™ review before you sign.

Contact ClaimInformatics: hello@claiminformatics.com · claiminformatics.com · 860.761.9570

What's the number one data access barrier your plan is facing right now? Share in the comments — Stephen will be engaging after the session.