Relentless Health Value

Is Your TPA Truly Independent? The One Claims Audit Question to Ask, With Kimberly Carleson (EP534)
The Red Flag Question That Reveals Whether a TPA Works for Your Plan or for the Network. Episode 534.
What's a practical, speedy way to assess whether a TPA (third-party administrator) is truly independent and willing to protect the plan sponsor's interests, versus being captive to network contracts, carrier relationships, or other conflicts of interest? In this Ask Me Anything, Stacey Richter puts that question to Kimberly Carleson, CEO of US Beacon, one of the nation's most established independent medical and pharmacy claims compliance and integrity review firms. Her answer is a big kahuna of a tell: ask whether the TPA will let someone come in and independently review your claims — and listen closely to the response.
WHAT YOU'LL LEARN
✅ The one question that quickly exposes whether a TPA is truly independent: "Can we have someone come in and independently review our claims?"
✅ Why a TPA answering "We have network contracts that restrict that" is a red flag — it means they are working for the network, not the plan
✅ What a TPA should hand over without hesitation when a plan sponsor asks for an independent claims audit: all claims data, including billed, paid, and allowed charges
✅ How blocking language in TPA and network contracts — restrictions on accessing data or contacting providers — can stop a plan from independently reviewing its own claims and payments
✅ How an "independent" TPA can still be beholden to a network, renting that network and acting the same way any BUCA would
✅ Why labels like "transparent" and "independent" aren't proof, and why due diligence matters: talk is cheap
WHY THIS MATTERS
Plan sponsors who go self-funded want to do their own thing and bring in their own vendors, not end up "self-funded in name only," as Jonathan Baran calls it. But irrespective of what a partner calls itself, it's still really important to validate what you hear. A TPA's willingness to let you bring in your own auditor — with access to the data and no blocking language in its network contracts — is a fast way to find out whether it works for the plan or for the network. And as Kimberly says, if you can't bring in who you want to bring in, there's something they don't want you to see.
MENTIONED IN THIS EPISODE
EP518 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps
Website: US Beacon
Kimberly Carleson on LinkedIn
=== LINKS ===
🔗 Show Notes with all mentioned links: Show Notes
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter
🫙 Support the podcast with a small donation to the Tip Jar
🎤 Follow us on Apple Podcasts
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📺 Subscribe to our YouTube channel
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X
00:00 Introduction to this episode.
01:19 The conversation with Kimberly Carleson.
02:24 The one question to tell if a TPA is independent.
03:30 Breaking down the thought process behind this question.
05:59 How an independent TPA can still be beholden to a network.
06:48 Why it's so important to do due diligence.

Level-Funded Health Plan Risks: ERISA Contract Traps, Stop-Loss Gaps, and Surplus Fine Print. Episode 533.
An employer with a fully insured plan told Stacey Richter his renewal this year was 69% — his broker negotiated it down to 50%, which she's not sure she'd classify as a victory. Level funding looks like a lifesaver in that spot, but as Frank Pennachio, author of The Silent Danger and a health insurance veteran with nearly 40 years of experience, explains, level funding is self-funding, with all the fiduciary risk that comes with it. Frank walks through five avoidable contract risks that level-funded plan sponsors fall into regularly, from embedded ERISA violations to stop-loss misalignment to surplus fine print.
WHAT YOU'LL LEARN
✅ Why level funding is self-funding — it feels like a fully insured plan because of the flat monthly payment, but the plan sponsor carries the risks and benefits of self-funding, including fiduciary responsibility
✅ How third-party administrator (TPA) and administrative services only (ASO) agreements can embed ERISA violations the moment they're signed, and why ERISA allows personal assets to be exposed
✅ How stop-loss misalignment leaves the plan sponsor on the hook when plan promises, like eligibility for employees on approved leave, aren't reimbursed under the stop-loss contract
✅ The surplus fine print: incurred but not reported (IBNR) factors, service fees Frank has seen as high as 30%, and surplus returned as an invoice credit instead of a check
✅ Why claims data access promised up front can get signed away, and why fiduciaries must pay prudent fees — like a $50,000 charge to reprice one hospital bill
✅ Four action items: never sign a contract as is, educate the plan sponsor team, run a legit RFP, and pick a broker or EBC with experience and financial alignment
WHY THIS MATTERS
With renewals like 69% and 50%, there's a lot of desperation out there for a lifesaver, and level funding is being sold as one. But as Frank Pennachio quotes Thomas Sowell, "There are no solutions, there are only trade-offs," and the goal is for plan sponsors to pick the trade-offs they want rather than desperate ones. The cost increases will sting, Frank says, and they won't likely bankrupt most companies, but the risks you unknowingly assume could.
MENTIONED IN THIS EPISODE
Website: The Silent Danger, Frank Pennachio's book
Website: The Silent Danger courses from Frank Pennachio
EP478 with Andreas Mang and Jon Camire (Part 1): Apple Podcasts | Spotify | Other Apps
EP479 with Andreas Mang and Jon Camire (Part 2): Apple Podcasts | Spotify | Other Apps
LinkedIn Post by Kimberly Carleson
LinkedIn Post by David Goldfarb on stop-loss cost trends
EP512 with Doug Aldeen: Apple Podcasts | Spotify | Other Apps
EP457 with Cynthia Fisher: Apple Podcasts | Spotify | Other Apps
Study: Survey by Kaiser Family Foundation
EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps
EP433 with Justin Leader: Apple Podcasts | Spotify | Other Apps
=== LINKS ===
🔗 Show Notes with all mentioned links
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter
🫙 Support the podcast with a small donation to the Tip Jar
🎤 Follow us on Apple Podcasts
🎤 Follow us on Spotify
📺 Subscribe to our YouTube channel
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn ✭ Threads ✭ Bluesky
00:00 Introduction to this episode.
03:37 An overview of today's conversation.
04:57 What level funding is.
06:20 Why level funding is having an explosion in popularity.
08:03 What does an employer need to take into account when considering level funding?
09:36 The first risk of level funding.
12:24 The second risk of level funding.
15:01 The third risk of level funding.
19:45 The fourth risk of level funding.
21:46 The fifth risk of level funding.
24:41 Actionable strategies when considering level funding.
33:30 A summary of advice for level funding.

Emergency Department High Utilizers and Real-Time Care Coordination, With Chris Klomp (Episode 532)
Today we are dipping into the archives for an essential replay from 2016, one decade ago, featuring Chris Klomp back when he served as CEO of Collective Medical, and now nominated to serve as deputy secretary of the Department of Health and Human Services (HHS), a nearly $2 trillion federal health apparatus. In this conversation, Klomp explains why emergency medicine is only 2 to 4% of total U.S. healthcare cost, so avoidable ED spend can't be more than about 0.8 to 0.9% of total spend, and why the emergency department is still the natural choke point for finding complex, high-risk patients. Listening back is a rare, candid preview of the operational philosophy which may now shape Chris Klomp's view on health policy.
WHAT YOU'LL LEARN
✅ Why Klomp said in 2016 that emergency medicine is only 2 to 4% of total U.S. healthcare cost, versus about 6% for plan sponsors now
✅ How the ED works as a "clearinghouse" for physical, mental, behavioral, and social complexity, and why the goal is the right care setting, not stopping the visit (EMTALA)
✅ How a Pacific Northwest clinical group used real-time data and coordinated care plans to cut hospital readmission rates by close to 40%
✅ Klomp's four building blocks: real-time data (starting with an ADT feed, since claims data runs 90 to 180 days late), risk analytics, communication inside the EHR workflow, and community-wide collaboration
✅ How whole-person care took "Ron" from 23 ED visits in a month across seven hospitals to 3 at peak, and why 78% of ED high utilizers have physical, mental, and behavioral health comorbidities
WHY THIS MATTERS
With the nomination of Chris Klomp to serve as deputy secretary of HHS, all eyes are kind of on how he plans to manage a nearly $2 trillion federal health apparatus. The emergency department is a critical choke point through which complex, often high-risk patients inevitably pass. Not dealing effectively with these larger community issues costs everyone more than dealing with them effectively would cost, and if the country had done more of what Klomp describes ten years ago, it makes you wonder how things would be different now.
MENTIONED IN THIS EPISODE
EP467 with Stacey Richter: Apple Podcasts | Spotify | Other Apps
EP495 with Mick Connors, MD: Apple Podcasts | Spotify | Other Apps
EP464 with Al Lewis: Apple Podcasts | Spotify | Other Apps
Study: Research from Peter Smulowitz, MD, MPH; Leah Honigman, MD; and Bruce Landon, MD, MBA
EP322 with Monica Lypson, MD, MHPE: Apple Podcasts | Spotify | Other Apps
EP473 with Kenny Cole, MD: Apple Podcasts | Spotify
EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps
=== LINKS ===
🔗 Show Notes with all the mentioned links and article: Show Notes
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter
🫙 Support the podcast with a small donation to the Tip Jar
🎤 Follow us on Apple Podcasts
🎤 Follow us on Spotify
📺 Subscribe to our YouTube channel
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X
00:00 Introduction to this episode.
04:38 Reducing wasteful spend in healthcare.
05:37 The percentage of total healthcare costs that goes to emergency medical spend in the U.S.
07:09 Why ED spending is low-hanging fruit.
08:17 How EDs operate as choke points.
09:14 Impacting what happens in the emergency department.
17:34 What happens when a patient enters the ED.
20:57 Why it's important to have data available to everyone who might touch the patient.
24:45 The need-to-know when it comes to managing data.
28:01 Thinking about risk and imminent readmission.
30:01 Collaboration in a care plan to reduce wasteful spend.
30:53 The right data, risk analytics, communication, and community-wide collaboration.
31:11 How social determinants affect wasteful spend in the ED.

Discount Illusions, Billing Errors, and Site-of-Care Markups: A Carrier Network Primer for Employers with Evan Anderson of Handl Health. Episode 531.
Whatever the plan was at the very beginning, the big status quo carrier networks have evolved into what Stacey Richter calls a three-headed monster: the contractual illusion of discounts, payment integrity nobody with skin in the game is allowed to check, and wild site-of-care price swings inside the very same network. Stacey talks with Evan Anderson of Handl Health, where he works on product strategy, general strategy, and operations, about how fee-for-service networks got here and what self-insured employers, brokers, and TPAs can do around the edges right now. Consider it a primer — a survey of the general map of the landscape, with breadcrumbs to many past episodes for anyone ready to take a deep dive.
WHAT YOU'LL LEARN
✅ Why a discount off a chargemaster price is "an optical illusion" — including the 2023 Health Affairs finding that at roughly half of hospitals, the discounted cash price is lower than the insurer-negotiated rate
✅ How old mainframe adjudication systems, obtuse contracts, and double-digit billing error rates make payment integrity nearly impossible to verify — because where there's mystery, there's margin
✅ How site-of-care differentials drive runaway spend, from hospital multipliers as high as 13X to $135 vs. $13,560 for the exact same infusion drug — both in-network
✅ Why switching carrier networks, even with your own claims file and transparency data, is a shrinking lever as prices regress toward the mean
✅ Three around-the-edges moves: direct contracting for advanced primary care and Centers of Excellence, steerage and tiering that include site-of-care tiers, and bundled episodes of care aggregated into alternative health plans
✅ How the broker/EBC role is shifting from network shopper to plan orchestrator
WHY THIS MATTERS
These networks are, lest we forget, built on a fee-for-service model that structurally aligns incentives in ways that are a lot of times misaligned with members and plan sponsors. As Evan puts it, cut one head off and the body grows it back — that body being decades of opacity (gag clauses were only banned by the CAA in 2021) and intermediaries paid in ways indifferent or positively correlated to higher spend. For plan sponsors facing extreme increases, knowing the real price, the quality, and what was actually billed is how you start chipping away at the status quo.
MENTIONED IN THIS EPISODE
EP505 with Ahilan Sivaganesan, MD: Apple Podcasts | Spotify | Other Apps
EP434 with Benjamin Schwartz, MD, MBA: Apple Podcasts | Spotify | Other Apps
Website: Handl Health
Handl Health on LinkedIn
Evan Anderson on LinkedIn
Article: Katy Talento, ND, ScM, on a post-network world
LinkedIn Post by Mark Cuban
LinkedIn Post by Craig Gottwals
Study: Health Affairs, hospital cash prices vs. negotiated prices
EP482 with Preston Alexander: Apple Podcasts | Spotify | Other Apps
EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps
EP521 with Andrew Tsang: Apple Podcasts | Spotify | Other Apps
Article: Jim Jusko, JD, on healthcare provider networks (Medical Economics)
EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps
EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps
EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps
EP398 with Jacob Asher, MD: Apple Podcasts | Spotify | Other Apps
LinkedIn Post by Mike Hopkins
EP528 with Yashaswini Singh, PhD: Apple Podcasts | Spotify | Other Apps
LinkedIn Comment by Lori Smith Guliano
LinkedIn Comment by Patrick Nelli
EP509 with Patrick Nelli: Apple Podcasts | Spotify | Other Apps
EP504 with Ryan Jacobs: Apple Podcasts | Spotify | Other Apps
EP530 with Jake Velie and Keith Hartman, RPh: Apple Podcasts | Spotify | Other Apps
EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps
EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky: Apple Podcasts | Spotify | Other Apps
EP294 with Steve Schutzer, MD: Apple Podcasts | Spotify | Other Apps
=== LINKS ===
🔗 Show Notes with all mentioned links
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter
🫙 Support the podcast with a small donation to the Tip Jar
🎤 Follow us on Apple Podcasts
🎤 Follow us on Spotify
📺 Subscribe to our YouTube channel
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X
00:00 Introduction to this episode.
02:21 An overview of today's conversation.
06:31 The conversation with Evan Anderson.
06:40 What is a network?
08:15 The reality of contracts and care networks.
13:19 The contractual illusion of discounts.
21:17 What does a good solution look like right now?
24:35 How incentivizing providers can open opportunities.
26:44 How COE and steerage architecture plays into this.
34:02 The different role of the broker and EBC in this model.
35:59 What Handl Health is and does.

The Hidden Link Between Expensive Infusions and Rising Stop-Loss Renewal Premiums. Episode 530.
When an infusion claim lands on a self-insured plan's high-cost claims report, it's tempting to treat the price tag as fixed — but the exact same infusion drug can cost 10 times more depending on where a member receives it, and every expensive claim that breaches a stop-loss attachment point can push next year's premium higher or get that member's claim lasered off coverage entirely. In this episode, Stacey Richter talks with Jake Velie, founder, chairman, and CEO of National Integrative Health (NIH), and Keith Hartman, RPh, NIH's chief strategy officer, about the direct — not dotted — line between overpaying for infusions and overpaying for stop-loss coverage, and the four pillars plan sponsors need to actually pull off site-of-care optimization.
WHAT YOU'LL LEARN
✅ Why there's a direct, not dotted, line between expensive infusion claims and rising stop-loss renewal premiums — and how breaching an attachment point can get a claim lasered off coverage
✅ How the opacity of J-codes and Q-codes on the medical benefit hides how much margin is built into an infusion's billed cost, unlike the more visible pharmacy-benefit claims data
✅ Why the exact same infusion drug can cost 10 times more depending on where a member receives it
✅ The four pillars of a real site-of-care optimization program: deep clinical oversight, proactive pre-cert intervention, plan design and financial incentives, and member/influencer engagement
✅ Why a vague "denied" fax in the pre-cert process leaves prescribing clinicians in the dark and can sabotage a site-of-care redirect before it starts
✅ How home infusion can be used as a site-of-care option even when an anticompetitive hospital contract otherwise restricts steering
WHY THIS MATTERS
Stop-loss coverage is usually a self-insured plan's single biggest expense, yet Stacey Richter points out that the typical reaction to an expensive infusion claim is to treat it like an unalterable fate. The same infusion can cost 10 times more depending on where a member gets it, and every claim that breaches a stop-loss attachment point pushes premiums higher or risks getting the claim excluded from coverage. As medical and pharmacy trend keeps climbing, knowing how to steer members toward lower-cost, clinically appropriate sites of care is becoming a core skill for plan sponsors — not knowing how is turning into a problematic knowledge gap.
MENTIONED IN THIS EPISODE
EP529 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps
EP370 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps
EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps
Website: National Integrative Health
EP501 with Ivana Krajcinovic, PhD: Apple Podcasts | Spotify | Other Apps
EP508 with Lee Lewis: Apple Podcasts | Spotify | Other Apps
EP480 with Kimberly Carleson: Apple Podcasts | Spotify | Other Apps
EP523 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps
EP472 with Eric Bricker, MD: Apple Podcasts | Spotify | Other Apps
=== LINKS ===
🔗 Show Notes with all mentioned links: Show Notes
✉️ Enjoy this podcast? Subscribe to the free weekly newsletter
🫙 Support the podcast with a small donation to the Tip Jar
🎤 Follow us on Apple Podcasts
🎤 Follow us on Spotify
📺 Subscribe to our YouTube channel
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn ✭ Threads ✭ Bluesky ✭ X
00:00 Introduction to this episode.
02:42 An overview of today's conversation.
05:50 The critical pillars plan sponsors underestimate.
07:44 Today's conversation with Keith and Jake.
10:08 Connecting the dots between infusion therapy costs and stop-loss coverage.
13:44 Why stop-loss carriers are starting cost-containment initiatives themselves.
17:36 The things many plans miss.
18:40 Why some plans miss or underestimate extensive clinical capabilities.
20:39 What does "good" look like, relative to a clinical team?
23:10 What do plan sponsors need to ensure further care fragmentation?
27:05 Why plan design and member financial alignment are so important.
29:44 Why is it important for plan sponsors to have a member and influencer engagement engine?
32:58 What about anti-competitive contracts and ASO resistance?
35:15 What National Integrative Health does.
36:22 Where you can go to learn more about National Integrative Health.