EP433: The Mystery of the Weekly Claims Wire: What Are Plan Sponsors Actually Paying For Each Week? With Justin Leader

Every week, self-funded employers get hit with a claims wire — a charge from their TPA or ASO vendor to cover plan expenses in weekly increments — and depending on how sophisticated the plan or its advisor is, that invoice might be a single lump total or a detailed breakdown. Justin Leader, president and CEO of BenefitsDNA, joins Stacey Richter to walk through five fees that frequently get buried inside that claims wire without ever showing up on an administrative invoice or in the ASO finance exhibit — plus a bonus mechanism, medical claims spread pricing, that moves money to vendors in ways plan sponsors often don't realize. WHAT YOU'LL LEARN ✅ What a shared savings fee is — including how it can quietly extend to overpayment recoupment fees, where a TPA charges the plan sponsor a percentage of money recovered after correcting its own mistake ✅ How prior auth fees, prepayment integrity fees, pay and chase fees, and TPA claims review fees each work, and why several of them charge extra for functions a TPA is arguably already being paid to perform ✅ Why so many of these fees are structured as a percentage of vendor-reported (and largely unvalidated) savings — and why that means the fees quietly grow every year right alongside medical trend ✅ What medical claims spread pricing is, and how a plan sponsor can end up paying a provider more than the actual check written for the service rendered ✅ Why identifying, reviewing, and documenting every fee in a vendor contract needs to become standard practice ahead of every renewal or RFP negotiation WHY THIS MATTERS If a fee has to be hidden to get paid, that alone is a signal worth taking seriously — even when the underlying service is legitimate. The core problem isn't that TPAs and ASO vendors charge for extra work; it's that plan sponsors are frequently paying for that work without ever agreeing to a known rate, without visibility into what's being charged, and without any way to validate the savings those fees are calculated against. For any employer or plan sponsor trying to control healthcare costs, understanding exactly what's buried in the weekly claims wire isn't a nice-to-have audit exercise — it's the baseline information needed to negotiate from a position of actual knowledge rather than trust. === LINKS === 🔗 Show Notes with all mentioned links: Episode Page ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X 00:00 Introduction. 07:55 How is the claims wire typically explained to a plan sponsor? 11:18 What is the whole point of self-funding? 11:27 Why is it so vital to understand what you're paying for? 12:38 What are the five "buried" items that wind up in these claims wires? 13:03 What is a shared savings fee? 17:10 "Rates are important, but so are your rights." 21:01 What's going on with prior auth fees? 23:35 What is prepayment integrity? 28:16 What is pay and chase? 31:54 What is a TPA claim review? 35:47 Is there medical claim spread pricing?