# Self-Funded Plan Guide For Payment Integrity Solutions

## Ensuring Fiduciary Compliance

A comprehensive guide for self-funded and captive health plan fiduciaries

### The Fiduciary Crisis

**Why You Must Act Now**

$74B Annual personal liability exposure for self-funded fiduciaries

Fiduciary compliance isn't a best practice— **it's a legal obligation**. Plan sponsors face mounting scrutiny, rising litigation, and evolving billing tactics.

The mandate: protect plan assets, monitor vendors, maintain defensible oversight.

📘 Learn more about [your fiduciary responsibilities under ERISA](https://www.claiminformatics.com/your-fiduciary-duties)

### The System Is Against You

**Hidden Conflicts Everywhere**

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

If you can't see your data and verify vendors—you can't meet your fiduciary obligation.

🔍 See how [independent oversight protects self-funded plans](https://www.claiminformatics.com/copy-of-self-funded-solutions)

### What Compliance Requires

**ERISA & CAA Mandates**

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?

**Bottom line**: You are accountable—not your vendors.

📋 Explore all [8 fiduciary duties in detail](https://www.claiminformatics.com/your-fiduciary-duties)

### Criterion #1: Full-Lifecycle Claims Oversight

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

A fiduciary partner covers the entire claim lifecycle.

⚙️ Learn about [ClaimInformatics' full-lifecycle solutions](https://www.claiminformatics.com/solutions)

### Criterion #2: Transparent, Defensible Methodology

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

Your process must be explainable, documented, and defensible.

### Criterion #3: Independence & Alignment

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

Partner success should equal your success.

🛡️ See why [ClaimInformatics is truly independent](https://www.claiminformatics.com/about-us)

### Criterion #4: Measurable Value & Recoveries

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?

If results can't tie to fiduciary reporting, it won't protect you.

### Criterion #5: Data Access & Transparency

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

Real-time visibility is the new standard.

### Criterion #6: Scalability, Security & Compliance

Enterprise-grade requirements:

- ✓ SOC 2 certified, HIPAA compliant
- ✓ All claim types (medical, Rx, behavioral)
- ✓ Smooth TPA/workflow integration
- ✓ Scales: small employers to large captives

Security is a fiduciary responsibility.

🏢 Solutions for [captive health plans](https://www.claiminformatics.com/copy-of-tpa-pre-pay-solutions) and [TPAs](https://www.claiminformatics.com/copy-of-post-pay-solutions)

### Criterion #7: Governance & Contract Integrity

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

Contracts must protect fiduciaries—not vendors.

### Criterion #8: True Fiduciary Alignment

Vendor selection, terms, recoveries, data access, and fees are all under your oversight.

Your partner must understand: You are accountable.

**100% Claims analyzed**

**50% Recovery share**

**0 Conflicts**

📊 See how ClaimInformatics delivers on all 8 criteria: [View our solutions](https://www.claiminformatics.com/solutions)

## Choose a Partner That Protects You

### Your Next Steps

### Ready to strengthen compliance?

[Schedule Free Consultation →](https://www.claiminformatics.com/contact)

### Why ClaimInformatics?

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.

- **100% Claims Analysis** Comprehensive oversight, not sampling—pre-pay editing and post-pay review to prevent and detect improper payments.
- **Defensible Audit Trail** Advanced analytics and proprietary logic to identify complex billing patterns while supporting regulatory compliance.
- **SOC 2 & HIPAA Compliant** Enterprise-grade security with industry-standard coding guidelines and transparent recovery share model.
- **Real-Time Dashboards** Near real-time insights into high-cost members, suspect providers, and top procedures—raw data transformed into actionable intelligence.

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**.

### See How We Can Protect Your Plan

[Get Your Free Fiduciary Risk Assessment →](https://www.claiminformatics.com/contact)