Self-Funded Plan Guide For Payment Integrity Solutions
Self-Funded Plan Guide For Payment Integrity Solutions
Ensuring Fiduciary Compliance
A comprehensive guide for self-funded and captive health plan fiduciaries
Fiduciary compliance isn't a best practice—it's a legal obligation. Plan sponsors face mounting scrutiny, rising litigation, and evolving billing tactics.
Relying on your TPA or network to "do the right thing" is not a strategy:
- •Networks profit from errors AND corrections
- •Revenue optimization favors providers, not plans
- •Auto-adjudication prioritizes speed over accuracy
- •Opaque systems hide billions in overpayments
Fiduciaries must demonstrate they acted:
- ✓Prudently
- ✓Loyally
- ✓With proper oversight
- ✓Per plan documents
Ask Partners:
- Analyze 100% of claims—not samples?
- Free of TPA/network conflicts?
- Provide defensible audit trail?
- Demonstrate measurable value?
Fiduciary compliance requires comprehensive oversight—not just pre-pay or post-pay:
- ✓Independent TPA/network analysis
- ✓1–3 year retrospective review
- ✓Pre-pay analytics to stop overpayments
- ✓Monthly post-pay with Episode-of-Care logic
- ✓Transparent recovery services
To withstand regulatory or legal scrutiny:
- •Industry-standard rules: CPT®, HCPCS®, ICD-10-CM, NCCI
- •Clear documentation: CARCs/RARCs for each determination
- •Drill-down dashboards: Claim-line detail access
Many vendors are tied to networks, TPAs, or providers. If they profit from higher claims—you lose alignment.
- ✓Vendor-agnostic (no network/TPA/PBM ties)
- ✓Aligned with plan objectives
- ✓No hidden conflicts
Compliance is about protecting plan assets with measurable results:
Ask Vendors:
- Typical savings (PMPM, % flagged)?
- Case studies or benchmarks?
- Clear recovery process?
- Cost-avoidance, not just recovery?
Fiduciaries must see the data—not just receive reports:
- ✓Dashboards: trends, outliers, provider patterns
- ✓Raw data access (not vendor-filtered)
- ✓Drill-down to claim/provider/episode level
- ✓Exportable audit reports
Enterprise-grade requirements:
- ✓SOC 2 certified, HIPAA compliant
- ✓All claim types (medical, Rx, behavioral)
- ✓Smooth TPA/workflow integration
- ✓Scales: small employers to large captives
Your vendor agreement should strengthen—not weaken—your posture:
- ✓Plan owns the data
- ✓Fees aligned with outcomes
- ✓Documented appeals process
- ✓Supports audit trails & board minutes
- ✓No hidden conflicts
Vendor selection, terms, recoveries, data access, and fees are all under your oversight.
Ready to strengthen compliance?
Schedule Free Consultation →Choosing a payment integrity solution isn't just cost control—it's a critical piece of your fiduciary duty. If you ignore data access, independent oversight, full claims lifecycle coverage, transparency, and measurable value, you expose your plan to hidden costs, regulatory scrutiny, and personal liability.
ClaimInformatics is a payment integrity solution specifically designed to protect plan fiduciaries. The platform is fully independent—earning no revenue from TPAs, networks, PBMs, or providers—ensuring your fiduciary interests come first.
ClaimInformatics empowers fiduciaries to fulfill oversight obligations, avoid hidden risks, and ensure plan assets are administered according to plan documents—making it the compelling choice for self-funded and captive health plans seeking both compliance and financial integrity.