The Payment Integrity Arms Race—RCM (Revenue Cycle Management) and Plan Sponsors, With Mark Noel

Revenue cycle management is a $140 billion industry — already larger than the US auto industry and growing five times faster. RCM vendors use programmatic clearinghouses and increasingly sophisticated tools to maximize every cent of revenue from a claim. That is their job. On the other side sits the self-insured employer, often relying on less sophisticated processes and vendors who may be financially incented to look the other way. It is, as Mark Noel puts it, an arms race, a tug of war, and a zero sum game. In this episode, Stacey Richter speaks with Mark Noel, CEO of ClaimInsight, who has spent roughly 25 years in payment integrity on the health plan, TPA, and self-insured employer sides, about three revelations buried in plan sponsor claims spend. WHAT YOU'LL LEARN ✅ Revelation 1 — The small claim goldmine: 80% of claims volume by count is professional claims — doctor's office visits, lab draws, vaccines — not inpatient surgeries. Overpayments of $2, $5, or $10 on thousands of claims add up to millions in annual waste, but most prepayment integrity resources are focused on the 20% of large claims while the small-dollar volume flies through unchecked ✅ Revelation 2 — The conflict of interest trap: asking a TPA to report on its own errors is like asking the person who filed your tax return to also conduct the penalty audit — and large ASO TPAs edit claims on their fully insured book (where the dollars come out of their own pocket) at materially higher rates than on ASO client claims (where the dollars come out of the employer's pocket) ✅ Revelation 3 — Shared savings perverse incentives: many carrier and TPA contracts allow them to earn shared savings on the backend for fixing errors they did not catch on the frontend — creating a direct financial incentive to let errors through prepayment so they can be "recovered" for a fee later ✅ Why prepayment integrity must happen at the TPA level: to catch small errors before payment, a payment integrity vendor must be connected to the claims processor in real time — retrospective review can show where a plan has been overpaying and inform TPA contract negotiations, but the real savings require integration upstream ✅ The Goldilocks problem with turning on edits: turning on every available policy creates excessive provider friction and can inadvertently flag legitimate claims — including in sensitive areas like cancer treatment — so the right approach is a deliberate conversation with the plan about what edits to turn on, not "maximize everything and react when providers bark" ✅ Why this is a member protection issue, not just a financial one: 41% of Americans have medical debt; when claims are overpaid and members are on co-insurance, the member pays a portion of that error too — payment integrity is both a fiduciary obligation and a direct protection for the people the plan is supposed to serve WHY THIS MATTERS The RCM side will be up to date. Every January, coding rules update and RCM vendors adjust immediately. Payment integrity vendors that are not keeping policies equally current are falling behind in real time. For self-insured employers who are relying on a TPA's in-house payment integrity program, the question worth asking is: are those edits running at the same level of rigor on your ASO claims as on the carrier's fully insured book? The honest answer, in most cases, is no. === LINKS === 🔗  Show Notes with all mentioned links:   https://cc-lnk.com/EP498 ✉️  Enjoy this podcast? Subscribe to the free weekly newsletter: https://relentlesshealthvalue.com/join-the-relentless-tribe ✉️  Visit ClaimInsight https://www.claiminsight.com/ 🫙  Support the podcast with a small donation to the Tip Jar: https://relentlesshealthvalue.com/join-the-relentless-tribe 🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1 🎤  Listen on Spotify  https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b 📺  Subscribe to our YouTube channel   https://www.youtube.com/@RelentlessHealthValue === CONNECT WITH THE RHV TEAM === ✭ LinkedIn   https://www.linkedin.com/company/relentless-health-value/ ✭ Threads  https://www.threads.net/@relentlesshealthvalue/ ✭ Bluesky   https://bsky.app/profile/relentleshealth.bsky.social ✭ X   https://twitter.com/relentleshealth/ 06:03 How millions of dollars can be recovered per year from smaller claims under $500. 07:46 EP486 with Stan Schwartz, MD. 09:10 How to get to payment integrity prepayment. 11:20 How payment processing efficiency is necessary to payment integrity. 13:59 How TPAs fit into the claims payment process and how they can add to payment integrity. 15:59 LinkedIn post from Chris Deacon. 16:50 EP433 with Justin Leader. 17:04 LinkedIn post from Justin Leader. 17:10 How shared savings incentives can be perverse incentives. 23:05 How employers are doing retrospective reviews. 24:29 How employers should be negotiating their TPA contracts. 25:41 EP285 with Dawn Cornelis. 25:43 EP480 with Kimberly Carleson. 27:40 Why it's imperative that payment integrity vendors are up-to-date on all policies. 30:00 EP497 with Zack Kanter. 31:13 What should self-insured employers do to assess their payment integrity?