ClaimInformatics Disrupts Payment Integrity with Flat-Fee Pricing to Eliminate Fiduciary Conflicts

Quick Summary

ClaimInformatics has launched a first-of-its-kind flat-fee pricing model for health plan payment integrity, replacing traditional percentage-of-savings models. This shift eliminates structural conflicts of interest, helping self-funded employers and TPAs meet strict ERISA fiduciary standards while protecting against a projected $74 billion in liability exposure.

How Does ClaimInformatics Solve Fiduciary Conflicts in Health Plans?

ClaimInformatics addresses the inherent bias in traditional payment integrity by removing contingency-based fees. In standard models, vendors only profit when claims are denied, creating a misalignment of incentives between the plan sponsor and the auditor. By moving to a flat, per-claim fee, the company ensures that its review process is objective and defensible under ERISA §408(b)(2) guidelines.

• Zero dollar thresholds for claim reviews, ensuring total oversight.
• No percentage-of-savings charges that penalize providers for corrected billing.
• Elimination of PEPM (Per-Employee-Per-Month) fees that inflate costs regardless of activity.

What Tools Are Available for Managing ERISA Liability?

To support the transition to conflict-free oversight, the company has released a Self-Funded Plan Litigation Tracker. This tool monitors 44 critical milestones across federal agency rules and court decisions. With the Fiduciary Pressure Index currently rated as "EXTREME," these resources provide a roadmap for benefits consultants and brokers to navigate the shifting regulatory landscape.

• 44 milestones tracked across ERISA, PHSA, and CAA frameworks.
• $74 billion estimated exposure in personal fiduciary liability for U.S. plans.
• Three specialized playbooks tailored for TPAs, brokers, and employers.

Why Is Independent Payment Integrity Critical Now?

The plaintiffs’ bar is increasingly targeting health plan fiduciaries, mirroring the litigation wave that hit 401(k) plans. ClaimInformatics argues that relying on carriers (BUCAs) to police their own claims is no longer a prudent fiduciary process. Independent oversight acts as a necessary control layer, ensuring that plan dollars are managed with the same scrutiny as retirement assets.

“The fiduciary standard for health plans is catching up to where retirement plans already are, and it is happening fast. Plan sponsors, brokers, and TPAs are all being asked the same question: Can you prove your process was prudent, and that your vendors’ incentives are aligned with the plan’s interests? The tracker, these playbooks, and a pricing model with no stake in the outcome exist to give a direct, citable answer, before a regulator or a plaintiff’s attorney asks it for you.” said Stephen Carrabba, CEO & Co-Founder, ClaimInformatics™.

FF NEWS TAKE:

This move by ClaimInformatics definitely moves the needle by challenging the "hidden" fee structures of the insurance industry. By adopting payment integrity models that mirror the transparency of the fintech and retirement sectors, they are forcing a long-overdue conversation on fiduciary accountability. For self-funded employers, this isn't just a pricing change; it's a vital legal shield in an increasingly litigious healthcare environment.