ClaimTalk

Purchasing healthcare didn’t become this complicated overnight. So how did we get here? Our industry experts — CEO Ben Krambeck, Vice President of Provider Relations Brad Hansen and Vice President of Audit Services Cynthia Swanson — join Danielle Young on a new ClaimTalk to trace the policy decisions, reimbursement shifts and billing changes that helped create today’s health insurance mess.From the Affordable Care Act to questionable billing practices to the coding complexity still driving costs and confusion, their conversation breaks down how the system changed — and how understanding that history can lead to better decisions for employer health plans.

Convincing consultants to bring reference‑based pricing to clients isn’t easy. Paul Saunders, executive vice president at Saunders & Company, knows firsthand as someone who once was "totally opposed" to RBP. That changed when he saw how a dual‑option approach could work: pairing a traditional health plan with a lower‑cost RBP option and letting members choose what fits them best.In this month's episode of ClaimTalk, Saunders joins ClaimDOC’s Omar Arif and Stephanie Mohr to explore how dual‑option plans help brokers address rising renewal costs without forcing employers into an all‑or‑nothing decision. They explore why offering choice may be the most practical path to affordability, client confidence and long‑term satisfaction.

Who's a good third-party administrator? There are many to choose from, but far fewer that consistently deliver when it matters. And the difference between a good TPA and a mediocre one often determines whether a health plan works exceptionally well or frustrates everyone it touches.Our last two episodes of ClaimTalk weren't kind to TPAs. While much of that criticism was earned, the reality is that TPAs operate in a landscape that is complex, constrained and often misunderstood.On this episode, Luke Schafer of BRMS joins Danielle Young, Shay Butler and Dallas Lovell to discuss why the strongest TPAs are the ones that stay in their lanes and are laser-focused on their primary responsibility — paying claims.

Selecting the right vendors for a reference-based pricing health plan isn’t an exact science. At the end of the day, it often comes down to experience, discernment, and the ability to read the signals vendors give off long before the contract is signed.In this episode of ClaimTalk, Emma Fox, CHVA joins Danielle Young, Bruce Hansen and Stephanie Mohr to continue their unapologetically candid examination of vendor dynamics to offer pointed insights on evaluating partners that can make or break a self-funded strategy. They break down what truly constitutes “good” and “bad” vendor vibes, define what real competency actually looks like, and outline how to identify red flags before they turn into costly mistakes.If you’re serious about elevating your self-funded health plan performance, this conversation cuts through the noise and shows you what to look for, because not every vendor deserves a seat at your table.

Building a successful self-funded health plan demands skilled and efficient vendor partners that have the expertise to deliver on their promises. Identifying the best vendors can be challenging, and settling for substandard partners can lead to less-than-desirable outcomes. But how do you find the best partners?On this episode of ClaimTalk, Emma Fox, CHVA gets brutally honest during the first half of a two-part conversation with Danielle Young, Bruce Hansen and Stephanie Mohr on the struggles that can arise with vendors. While a good portion of the discussion centers on the issues they've experienced with third-party administrators, they also discuss why it can be difficult to find the right partners, the strategies they use to identify dependable vendors, and why some of the most unreliable vendors continue to survive in the industry.

In 2022, Featherlite Trailers partnered with ClaimDOC to begin implementing a new reference-based pricing health plan for its employees. It's no secret that moving to an RBP plan can come with friction but, with Shannon Westin, SHRM-SCP leading its human resources department, Featherlite didn't just endure the change, they owned it. Westin joins Danielle Young and Amy Hansen on ClaimTalk this month to share how taking the time to truly understand the plan and being proactive in resolving potential issues caused watercooler talk to shift from uncertainty to appreciation. 

If your organization sponsors a self-funded health plan and cybersecurity isn’t part of your vendor evaluation criteria, it’s time to reassess. Protecting your own infrastructure is essential, but it’s not enough. Every vendor with access to your data must meet rigorous cybersecurity standards. Otherwise, you're not just accepting risk, you're creating it.In this episode of ClaimTalk, Andrew Smith and Jeremy Schuller share with Danielle Young some of the threat tactics that cybercriminals are using today and discuss best practices in evaluating vendors to ensure your data will be secure.

Paying cash for healthcare services is not a new concept, but it's also an option that is not widely used. The reason for that is because many providers prefer to accept reimbursement from insurance. But cash pay does have its advantages.On this episode of ClaimTalk, Danielle Young visits with Amy Pellegrin and Leah DeBartolo about the pros and cons of cash pay, how health plans can create service around cash pay, and what stands in the way of cash becoming a more popular payment option for healthcare.

For nontraditional health plans to work — whether they use reference-based pricing or another strategy — they often require customized solutions. As health plans evolve, vendors can't ignore new methods to give plan members what they need.In this episode of ClaimTalk, Amy Pellegrin and Stephanie Mohr visit with Sharla Mallett, a member of our direct primary care team. They discuss how the DPC team works to give members a more personalized health plan experience and why making adjustments to health plans is crucial to providing a positive member experience.

Whether you're using a reference-based pricing strategy or some other alternative, there are many challenges in creating an effective direct contract. Much of the time, they boil down to the complexities of healthcare pricing in one way or another. Whether it's compliance with regulations, plan design or services billed by a third party, creating an effective direct contract requires a partner with the expertise to help you maneuver through all elements of the agreement.This month, Jay Kempton, Shane Cerone and Brad Hansen return to ClaimTalk for the second half of an in-depth discussion on direct contracts and how to navigate inconsistencies in healthcare pricing. 

Healthcare access can be the biggest hurdle to successfully implementing a reference-based pricing plan. Sometimes it requires creating an agreement called a direct contract between a health plan and a provider to ensure access to that provider. Direct contracts are an effective tool for RBP health plans, but they can be more complicated than they sound. On this month's ClaimTalk, experts Jay Kempton, Shane Cerone and Brad Hansen discuss the complexities of direct contracts and their impact on the rising cost of healthcare.

Claim denials are a complex piece of the healthcare system, and they can cause frustration for patients and providers alike. There are many reasons claims can be denied, whether it's due to technical errors, subrogation or if it's deemed not medically necessary.Experts Alex Arnet, Colton Casonand Carrie Kennedy join this month's edition of ClaimTalk to peel back all the layers of claim denials and share their insights on how its time to rethink this process.

A strong balance bill defense is essential to a successful reference-based pricing health plan. But what does that look like? And how do you know what you're being offered isn't just lip service? The answer is fiduciary responsibility.ClaimDOC Balance Bill Manager Alex Deeter and Chief Legal Officer Amy Pellegrin join this month's edition of ClaimTalk to discuss why it's important to choose a partner that sees balance bill defense as an obligation rather than a service.

In the second half of a two-part episode on PBMs, experts Marc A. Sweeney, Trevor Daer and Mike Kroupa return to discuss some of the intricacies of the pharmaceutical industry. They tackle complex topics like international drug sourcing, specialty drugs, GLP-1s and more.

There are several key vendor decisions brokers and plan sponsors must make when unbundling a self-funded health plan, including pharmacy benefit management. On a new episode of ClaimTalk, self-funding experts Marc Sweeney, Trevor Daer and Mike Kroupa will help you evaluate if you're making the best decision on your drug spend.

BUCAs may seem like the easy, all-inclusive choice, but they don’t offer the personal, one-on-one assistance most health plan members actually prefer. Plus, no plan sponsor should accept inferior member service — whether big network or reference-based pricing. In this month’s episode of ClaimTalk, Michelle Henaman and Heidi Martinez share the gaps in service you need to DEMAND get filled for your clients.

In this month's episode of ClaimTalk, brokers and industry experts Craig Gottwals and Mike Kerns are back for ADVISORS UNLEASHED — Part 2. They go even deeper into the benefits consulting industry, offering more brutally honest insights you won't hear anywhere else.

This month's edition of ClaimTalk is the first half of a two-part discussion with brokers and industry experts Craig Gottwals and Mike Kerns. They provide an inside look at the benefits consulting industry in a no-holds-barred conversation you won't want to miss.

Access will always be an obstacle with RBP medical plans. At ClaimDOC, we believe obstacles can be overcome. Our first wave of attack is proactive provider education through Pave the Way. When that’s not working, we turn to Austin Miller and our team of fixers. Learn more about Austin's journey at ClaimDOC and how our provider relations team uses data and relationships to ensure access in a new episode of ClaimTalk.

As a fiduciary, you are responsible for ensuring medical claims are billed accurately. If your plan administrator is prevented from auditing claims due to the network contracts, who is fulfilling this duty? Cynthia Swanson and Amy Pellegrin join this month's episode of ClaimTalk to discuss egregious billing practices and what it is required to be a compliant fiduciary. 

How do you silence RBP noise? In this month's episode of ClaimTalk, we interview rock star member advocate Amanda Ogg, and our training manager, Lori Van Groningen, about how they approach the challenges facing our members. There would be no headache-free direct access to care or cute baby pictures without their efforts.

Direct contracts are very different from direct access. In our latest episode of ClaimTalk —Winning the RBP Access War, With or Without Contracts — two of our legal experts share how we interact with providers to make sure DirectAccess+ members can receive medical care when they need it and from whom they want to receive it. 

Is the member experience too challenging with reference-based pricing programs? Listen to Bruce and Stephanie discuss the challenges our member advocates face each day as they help members navigate their medical plans. And hear about the successes they achieve directly from one of our member advocates.

No Surprise, the No Surprises Act has unintended consequences when administrative errors are costing plans money.  Join us and we'll share some horror stories from open negotiations and tips for making sure your clients aren't just compliant, they are protected. #ClaimTalk #Transparency #NSA

Get ready for a podcast that explains the complexities of cost containment and shares industry insights! Our team of experts will share their passion with the world in our new podcast, ClaimTalk. Subscribe now!

ClaimDOC is jumping into podcasting by launching ClaimTalk. Each month, you can look forward to a new episode filmed directly from our headquarters in Des Moines, Iowa. We won't be turning anyone into a benefits celebrity, but we will be hitting on issues we feel don't typically get expressed to audiences in ways that will make them better consumers. Stay tuned for the release of our first episode on April 10th, where we discuss the No Surprises Act, some open negotiation horror stories, and more. Subscribe now so you never miss an episode. #ClaimTalk #Transparency #NSA