Podcasts about tpas

It's that time of the year as ARY ROSENBAUM talks about his most known topic, the problem of ADP and Paychex operating as 401(k) TPAs.

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Send us Fan MailYvonne and Rafael sit down with Dave Chmiel, Chief Claims Officer at Hub International. Together, they engage in a great conversation about the broker's perspective on workers' compensation.Episode Highlights☕ The Core Message: Listening Changes Everything (00:02:38)From day one in the brokerage world, Dave was taught to listen, to understand what economic buyers (CEOs, CFOs) actually care about. That skill transcends the boardroom. When you truly listen, you access perspectives you'd otherwise miss. In workers' comp, where we're managing human situations, that's everything.

In this episode of Insurance Shoptalk, host Eric Stein sits down with James Benham, founder of JBK and Terra, host of the InsureTech Geek Podcast, and a longtime technology leader in the insurance industry. James shares insights from more than two decades building software, claims systems, underwriting platforms, and automation tools for carriers, TPAs, MGAs, and brokers across the insurance ecosystem. The conversation dives into how AI is transforming insurance operations, underwriting, claims management, and data analysis, while also addressing the challenges agencies and MGAs face with legacy systems, workflow automation, and implementation strategy. Eric and James discuss practical ways insurance professionals can start leveraging AI tools today, where machine learning and predictive analytics are headed next, and why agents who take the time to deeply understand these technologies will have a major advantage moving forward. If you're interested in the future of insurance technology, AI, underwriting, claims, automation, or operational strategy, this episode is packed with valuable insights and practical takeaways. #InsuranceShopTalk #Insurtech #AIinInsurance #ClaimsManagement #Underwriting #InsuranceTechnology #CommercialInsurance #MGA #TPA #WorkersComp

The 401k Girls are back. Hayley Porter and Jessica Porter return to talk acquisitions, target-date funds, financial literacy, vibe coding, and getting more women into financial services. Plus Fact or Fiction Thursday, a Chat Bar Champion challenge, and the usual chaos. We dig into the Ascensus and American Trust custodian shakeup and what consolidation means for advisors and TPAs, the wave of public comments on the latest DOL rule, whether private assets belong inside target-date funds, and why retirement should maybe just be boring. The girls break down their approachable take on financial literacy, the rebrand to The 401k Girls, and how authenticity (and the occasional quarter-zip) wins on social media. We also get into AI and vibe coding for plan administration. 0:00 Validate everyone in the chat bar 1:30 Welcoming back The 401k Girls 1:57 Fact or Fiction Thursday 4:50 Ascensus and American Trust custodian shakeup 13:30 Wholesaler relationships and partner reactions 20:50 DOL rule draws 37,000 public comments 23:30 Private assets inside target-date funds 27:20 Chat Bar Champion challenge 29:30 Reading bad financial advice posts 36:30 Making financial literacy approachable 38:40 Rebranding to The 401k Girls 41:30 Authenticity wins on social media 43:50 Vibe coding and AI for plan admin 49:50 Getting more women into financial services 59:00 Setting sales goals and succession planning 1:04:00 Wrap up and shoutouts Guests: Hayley Porter and Jessica Porter, The 401k Girls LinkedIn: https://www.linkedin.com/company/the-401k-girls Retireholics is a live show for the 401(k) industry. New episodes the 1st and 3rd Thursdays at 4:30pm Pacific. Join the next show live: https://plandesign.zoom.us/w/760355487 More episodes and transcripts: https://retireholics.com

Send us Fan MailYvonne and Rafael are so excited (and you can tell!). Yvonne declares she's Sandy's biggest fan! And honestly? After listening to this conversation, you'll understand why. Sandy Avina has figured out something our industry has been struggling with for over 100 years: how to make workers' compensation accessible, engaging, and even fun.Sandy Avina, MBA, is a Claim Services Manager with California Schools JPA, a self-insured public risk pool that serves K-12 school districts, community colleges, and regional occupational programs throughout San Bernardino County, California.What we get into:

In this installment of The Phia Group's Empowering Plans podcast, attorneys Kendall Jackson and Jon Jablon break down the Medicare Secondary Payer Act and what it means for self-funded group health plans. From prohibited incentives to noncompliant plan language, and the surprisingly thin line between educating and encouraging employees about Medicare, this episode covers the compliance pitfalls that plan sponsors, TPAs, and brokers sometimes overlook when trying to be cost-conscious. 

Employers are fighting rising healthcare costs, and this week's guest breaks down three powerful tools that actually move the needle. We sit down with Heath Potter, Chief Growth Officer at Six Degrees Health, to unpack reference‑based pricing, payment integrity, and member advocacy in plain, practical language.Heath shares how RBP replaces inflated PPO discounts with fair benchmarks—often around 140% of Medicare—helping plans cut medical spend by 25–40%. He also digs into the 18% claim error rate hiding in the system and why pre‑payment review on large claims is essential.You'll hear how self‑funded employers can structure their plans with TPAs and stop‑loss, how provider education and single case agreements smooth the process, and how balance bills are typically resolved through negotiation rather than escalation. Plus, why facility claims are where the biggest savings live.A clear, actionable conversation for anyone looking to take control of healthcare spend.To listen in and subscribe to more episodes, visit our website: fbmc.com/podcast.

There is recent evidence that OWCP (under the U.S. Department of Labor) has increasingly began to outsource significant portions of claims-related services for FECA (federal workers' compensation) to third-party vendors, including private companies traditionally known for state workers' compensation claims management. This is a change in the entire structure of the FECA and OWCP government division's responsibilities. OWCP has been slowly outsourcing divisions of OWCP to outside contracts in the form of third party vendors. This began with  medical bill processing (e.g., past transitions to vendors like CNSI now called ACCENTRA) and  medical authorizations.  This began when OWCP decided to outsource the pharmacy benefits to an outside corporate vendor called OPTUM, a pharmacy benefit manger to manage all of OWCP's pharmacy benefits. We can expect to see an increasing amount of companies continue to be added for specifically handling broad OWCP claims adjudication, the overall trend of outsourcing to experienced private-sector TPAs vendors from the state workers' comp ecosystem is now the wave of the future. For more information read the show transcript. The podcaster is Dr. Stephen Taylor, OWCP medical-legal consultant & DOL expert for Oberheiden Law Firm.  Dr. Taylor's contact email information is:https://fedcompconsultants@protonmail.com If you need a medical provider or assistance with an OWCP /  DOL claim in  Pensacola Florida you can make an appointment to see Dr. Taylor  at the clinic at  FWC Medical Centers . To make a consultation with Dr. Taylor  call the clinic at 813-215-4356  in Florida. For responses email Dr. Taylor at fedcompconsultants@protonmail.comSupport the showFEEDSPOT TOP #1 Federal Workers Compensation Podcast & #6 National Workers Compensation Podcast:For responses email Dr. Taylor at fedcompconsultants@protonmail.comSupport the showFEEDSPOT TOP 10 National Workers Compensation Podcast: https://podcast.feedspot.com/workers_compensation_podcasts/?feedid=5557942&_src=f2_featured_email

There's a growing movement in the restoration industry—one that says independent contractors don't need a franchise or a TPA to build a thriving business. Trusted Restorer has been making that case for years, and under its recently refreshed identity, the platform is reaching more contractors than ever with a simple but powerful message: you can scale, compete, and win on your own terms.

In this episode of "Voices of Self-Funding," host Ramesh Kumar sits down with Trey Hinson, Founder of Goliath Sales Strategies and a seasoned marketing and sales leader with over 24 years in the healthcare benefits space. Trey unpacks what authentic, research-driven sales and marketing look like in today's self-funded ecosystem. You'll learn: - Why modern brokers are demanding measurable outcomes, value-aligned proof, and a disciplined ICP strategy—and how carriers and TPAs can better meet those expectations. - The shift from feature-centric pitching to case-study-backed storytelling. - The importance of rep enablement for building a sales system that scales sustainably. This is a must-listen conversation for anyone looking to strengthen broker relationships, improve retention, and build sales systems that last. Tune in now! This episode is sponsored by zakipoint Health. At zakipoint Health, we are transforming the healthcare experience by delivering transparency, direction, and personalized support to members of self-insured plans. Our powerful platform unifies all benefit services, data, insights, and tools into one intelligent ecosystem empowering members to make informed decisions and take proactive steps toward better health outcomes. With AI at its core, zakipoint Health functions as the “Intel Inside” of healthcare navigation driving engagement, reducing risk, and delivering measurable cost savings. Employers and partners benefit from robust reporting, actionable insights, and tools that not only identify healthcare risks but also guide members toward high-value care. By bridging the gap between complexity and clarity in the U.S. healthcare system, we help organizations lower costs, improve outcomes, and support healthier, more engaged populations making healthcare less stressful and more effective for millions. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Episode 508 is the first Ask Me Anything installment of Relentless Health Value, where Stacey Richter and Lee Lewis (Chief Strategy Officer and GM Medical Solutions at the Health Transformation Alliance and host of Broken Benefits) address a question from benefits procurement leader Sarah Monroe about why executives rarely take bold action on health benefits despite large opportunity.  Lewis describes three false C-suite "dogmas" that lead to "stay in the herd and keep it quiet": health benefits are a fixed expense, saving money hurts people (via cost shifting, low quality, or narrow networks), and fixing healthcare isn't worth the risk or disruption. They also discuss external deterrents including CEOs' proximity to health system leaders, "balance of trade" retaliation threats, vendor-provided personal incentives, and executives' limited empathy for deductibles/costs faced by lower-wage employees.  Lewis offers de-risking tactics (same-network TPAs, carrier-enabled vendor changes, narrow pilots, mid-year tests) and advises CEOs to encourage bold action, tie bonuses to plan performance, and staff benefits teams with diverse skills. === LINKS ===

Send us Fan MailA single procedure can leave you with five bills, a stack of jargon, and the nagging fear that one surprise charge will hit collections. We wanted a better answer, so we sat down with Dr. Kikkeri, an anesthesiologist and pain management physician who helped build a bundled surgery model designed around one clear price, measurable quality, and a calmer patient experience.His motivation is not theoretical. He shares the moment that changed his career trajectory: seeing a patient with metastatic colon cancer after she stopped getting preventive colonoscopies because her deductible rose and she could not afford screening. That story pushes us into the real stakes behind transparent healthcare pricing and bundled payments. When access to care collapses under financial stress, “choice” becomes meaningless, and preventable disease becomes catastrophic.We break down what bundled surgery pricing actually means in practice: what is typically included in a bundle (facility, surgeon, anesthesia, routine pathology, and even implants in many cases), what may be excluded (certain imaging or pre-op specialty work), and why knowing the total cost upfront changes the clinical experience. We also talk about surgical navigation, quality metrics for surgeons and ambulatory surgery centers, and pre-op risk stratification that helps lower complications and infection rates. For self-insured employers and TPAs, we connect the dots to predictable surgical spend, reduced stop-loss pressure, and better member satisfaction.If you care about independent surgical centers, healthcare cost transparency, and building a system that feels human again, press play. Subscribe, share this with a colleague, and leave a review with your biggest question about bundled pricing.

A major storm hits the city. Sarah's bakery suffers roof damage, water leakage, and equipment loss. Sarah has heard lots of insurance job titles thrown around: policyholder, agent, broker, adjuster, underwriter, actuary-- who are all these people? In this preview of the PACE program's core on-boarding course, we'll explore the basics of the different roles in the insurance industry. Notable Timestamps [ 00:00 ] - The episode opens with a storm-damage scenario at Sara's bakery, setting up a practical lens for understanding insurance roles and how multiple professionals intersect during a single claim event. [ 00:59 ] - The lighthearted "Dec Page" segment underscores how real-world disruptions—like severe Midwest storms affecting travel—mirror the unpredictability that drives many insurance claims. [ 04:42 ] - The PACE program is practical and scenario-driven, aiming to demystify industry jargon and help both newcomers and experienced professionals apply concepts across claims and underwriting contexts. [ 06:25 ] - The "insurer" is the insurance company, while the "insured" is the policyholder. [ 08:02 ] - Insurance roles are tied to broader processes, including application, underwriting, claims handling, and premium rating, reinforcing that each role fits into a larger operational lifecycle. [ 10:11 ] - Agents typically represent the insurer (sometimes as captive or independent), while brokers represent the policyholder, helping match complex risks with appropriate carriers. [ 12:13 ] - Agents and brokers often remain involved beyond policy purchase, serving as trusted first contacts when a loss occurs and guiding policyholders through the claims process. [ 14:08 ] - Adjusters and claims professionals evaluate damage, determine coverage, and help restore policyholders, while TPAs and independent adjusters may be hired to handle claims on behalf of insurers. [ 16:46 ] - Because titles vary widely, professionals are encouraged to clearly introduce their role to policyholders, improving understanding and trust during what can be a confusing claims experience. [ 18:15 ] - Final takeaways reinforce core distinctions (insurer vs. insured), note that definitions may vary by policy, and highlight the importance of understanding agents, brokers, adjusters, and TPAs. Your PLRB Resources Sign Up for Updates on the Designation Program! https://2it6qrau8fd.typeform.com/pacedesignation Employees of member companies also have access to a searchable legal database, hundreds of hours of video trainings, building code materials, weather data, and even the ability to have your coverage questions answered by our team of attorneys (https://www.plrb.org/ask-plrb/) at no additional charge to you or your company. Subscribe to this Podcast Your Podcast App - Please subscribe and rate us on your favorite podcast app YouTube - Please like and subscribe at @plrb LinkedIN - Please follow at "Property and Liability Resource Bureau" Send us your Scenario! Please reach out to us at 630-509-8704 with your scenario! This could be your "adjuster story" sharing a situation from your claims experience, or a burning question you would like the team to answer. In any case, please omit any personal information as we will anonymize your story before we share. Just reach out to scenario@plrb.org.  Legal Information The views and opinions expressed in this resource are those of the individual speaker and not necessarily those of the Property & Liability Resource Bureau (PLRB), its membership, or any organization with which the presenter is employed or affiliated. The information, ideas, and opinions are presented as information only and not as legal advice or offers of representation. Individual policy language and state laws vary, and listeners should rely on guidance from their companies and counsel as appropriate. Music: "Piece of Future" by Keyframe_Audio. Pixabay. Pixabay License. Font: Metropolis by Chris Simpson. SIL OFL 1.1. Icons: FontAwesome (SIL OFL 1.1) and Noun Project (royalty-free licenses purchased via subscription). Sound Effects: Pixabay (Pixabay License) and Freesound.org (CC0).

Why do insurance executives keep funding AI pilots that never reach production — and what does it actually take to break the cycle?In this episode of Building Tomorrow's Insurer, host and Kanopi CEO Nigel Fellowes-Freeman sits down with James Benham, Founder and CEO of JBK and Terra, to diagnose the structural reasons AI transformation stalls in insurance organisations and what it takes to move from proof of concept to full-scale deployment.James brings 25 years of insurance technology experience to the conversation, having built bespoke systems for carriers, TPAs, MGAs, brokers, and ancillary providers since 2004. As CEO of both JBK — a full-service insurance technology consultancy — and Terra, a workers' compensation platform, James has sat at the executive table with insurers across the US implementing machine learning, workflow automation, and agentic AI at scale.Key themes covered in this episode:- Why insurers have always lived in Groundhog Day — and why AI is finally forcing them out of it- The CEO-COO-CIO trifecta: why misaligned leadership is the single biggest reason pilots die- Agentic AI versus RPA: what actually changes when you put a high-IQ brain on top of a workflow engine- Data, process, and tooling: which comes first in a real AI transformation roadmap- The metrics that matter — combined ratio, claim load per adjuster, underwriting throughput — and how to set them without accelerating the wrong outcomes- Why dedicated automation teams, not side-of-desk innovation, are the only path to productionEssential listening for insurance CXOs, CIOs, and transformation leaders who are tired of the pilot loop and ready to act.

In Episode 303 of the FNO: InsureTech Podcast, host Lee Boyd welcomes Phil McGriskin, Co-Founder and CEO of Vitesse, for a deep and timely discussion on one of the most complex, and often invisible, challenges in insurance: financial infrastructure behind claims payments. Phil shares his journey from Australia to the heart of the Lloyd's insurance market, tracing a career that spans underwriting, brokerage, fintech entrepreneurship, and large scale payments innovation. With multiple successful ventures behind him, Phil brings a rare perspective to insurance, approaching long standing problems through the lens of payments, treasury, and operational control. The conversation explores how Vitesse was built to solve the inefficiencies surrounding loss funds, delegated authority payments, and treasury visibility. Rather than focusing solely on speeding up payments, Phil explains why giving carriers real time insight, control, and transparency over capital is foundational to improving claims outcomes, reducing risk, and freeing trapped funds. Lee and Phil also discuss what it took to deliver meaningful change inside the 300 year old Lloyd's ecosystem, how fintech principles must adapt to insurance regulation, and why modernizing financial infrastructure requires collaboration across carriers, TPAs, MGAs, and brokers. The episode closes with Phil's pragmatic perspective on artificial intelligence within financial infrastructure, where AI can create real value today, and where human judgment and accountability must remain firmly in place. Key Highlights [05:30] – Phil McGriskin's Early Career, Moving from Australia to the Lloyd's Market How Phil's early experience in underwriting and brokerage shaped his understanding of insurance complexity. [09:15] – The Origins of Vitesse and Lessons from Building Global Payments Companies Why Phil returned to payments after exiting his first fintech business and what insurance was missing. [13:40] – Why Loss Funds and Treasury Visibility Became the Core Problem to Solve How carriers unknowingly tied up millions in poorly reconciled delegated authority funds. [18:55] – Modernizing Claims Payments Inside the Lloyd's Ecosystem What it took to deliver the Faster Claims Payment initiative across a 300 year old marketplace. [21:45] – Scaling Fintech in a Highly Regulated Insurance Environment Balancing innovation, regulation, and the realities of legacy insurance operations. [25:10] – Implementing Technology Across Carriers, TPAs, and MGAs Why successful transformation requires engaging every party in the insurance value chain. [29:20] – Expanding into the U.S. Through Lloyd's Connectivity and Regulatory Licensing How Vitesse leveraged existing market relationships to establish a U.S. footprint. [32:40] – Carriers, TPAs, and the Role of Tier One Banking Infrastructure Why treasury safety, regulation, and bank selection matter in insurance payments. [36:30] – Phil McGriskin on Responsible AI in Financial Infrastructure Where AI adds value today in treasury optimization and operations, and why humans must retain control over payment authorization. [40:15] – The Future of Financial Infrastructure in Insurance Why shared platforms, transparency, and trust will define the next phase of insurance innovation.

Stacey Richter interviews Jerry DiMaso, CEO of Payerset, about how hospital and carrier price transparency data (mandates beginning with hospitals in 2019 and carriers in 2022) is being used by plan sponsors and providers. For self-insured employers and unions, DiMaso highlights three key uses: benchmarking against competitors via EIN to compare negotiated rates and carve-outs, identifying high-cost billing codes, and exposing "discount shell games" by validating whether claimed discounts reflect real savings.  Employers can use the insights to guide TPA negotiations, implement service carve-outs/direct contracts and calculate objective savings, and model alternative plan types (e.g., PPO vs HMO) while maintaining access. For clinics, transparency data can level information asymmetry by enabling rate benchmarking, revealing new contracting opportunities with previously unknown carriers, and supporting rate increases by pairing price comparisons with quality/outcomes; the discussion also addresses concerns about prices rising and an emerging transparency "arms race." === LINKS ===

"I can't fathom a world where employers are expected to budget and create a plan for their future without understanding what the costs of their healthcare are. Everything needs to be grounded in fact and truth."Is the traditional insurance network obsolete?My guest this week is Amy Wykoff, Chief Product Officer at Nomi Health. After starting her career building foundational AI models at IBM Watson, Amy pivoted to healthcare with a massive new challenge: rebuilding the insurance network from scratch.In this episode, we explore Nomi's radical approach to the "Network as a Product." Rather than negotiating opaque discounts off inflated Charge Master rates, Nomi negotiates fair, transparent cash rates with providers and guarantees them 100% payment. In return, self-funded employers can offer their employees a true $0 copay, $0 deductible health plan.We discuss the logistics of building a direct-contracted network across 40 major MSAs, how to overcome "point solution fatigue" by reassembling the vendor stack, and why the ultimate goal of healthcare innovation should be to stop using AI to fight over claims denials - and start using it to improve actual patient care.Tune in to this week's Self-Funded to learn exactly how the free market is finally fighting back!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: IBM Watson & The Origins of Healthcare AI(00:02:56) Leaving AI to Build "Network as a Product" at Nomi Health(00:05:07) The $0 Copay, $0 Deductible Health Plan(00:07:09) Scaling a Direct-Contracted Network to 40 MSAs(00:08:44) The Insanity of Traditional Carrier Reimbursement(00:13:08) Why Providers Actually Want Transparent Cash Pricing(00:15:10) The Economic Drain: How Bad Networks Hurt Local Economies(00:19:07) Why Employees Hate Their Health Insurance(00:23:44) Reassembling the Vendor Stack: Navigation & TPAs(00:28:13) Why Healthcare is Now a CFO Decision(00:32:02) "The Tears of Joy": Real Patient Stories(00:37:31) The AI War: Why "Bots Fighting Bots" is a Waste of Talent(00:43:51) Closing Thoughts: Unbundling the Health PlanKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"I can't fathom a world where employers are expected to budget and create a plan for their future without understanding what the costs of their healthcare are. Everything needs to be grounded in fact and truth."Is the traditional insurance network obsolete?My guest this week is Amy Wykoff, Chief Product Officer at Nomi Health. After starting her career building foundational AI models at IBM Watson, Amy pivoted to healthcare with a massive new challenge: rebuilding the insurance network from scratch.In this episode, we explore Nomi's radical approach to the "Network as a Product." Rather than negotiating opaque discounts off inflated Charge Master rates, Nomi negotiates fair, transparent cash rates with providers and guarantees them 100% payment. In return, self-funded employers can offer their employees a true $0 copay, $0 deductible health plan.We discuss the logistics of building a direct-contracted network across 40 major MSAs, how to overcome "point solution fatigue" by reassembling the vendor stack, and why the ultimate goal of healthcare innovation should be to stop using AI to fight over claims denials - and start using it to improve actual patient care.Tune in to this week's Self-Funded to learn exactly how the free market is finally fighting back!Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: IBM Watson & The Origins of Healthcare AI(00:02:56) Leaving AI to Build "Network as a Product" at Nomi Health(00:05:07) The $0 Copay, $0 Deductible Health Plan(00:07:09) Scaling a Direct-Contracted Network to 40 MSAs(00:08:44) The Insanity of Traditional Carrier Reimbursement(00:13:08) Why Providers Actually Want Transparent Cash Pricing(00:15:10) The Economic Drain: How Bad Networks Hurt Local Economies(00:19:07) Why Employees Hate Their Health Insurance(00:23:44) Reassembling the Vendor Stack: Navigation & TPAs(00:28:13) Why Healthcare is Now a CFO Decision(00:32:02) "The Tears of Joy": Real Patient Stories(00:37:31) The AI War: Why "Bots Fighting Bots" is a Waste of Talent(00:43:51) Closing Thoughts: Unbundling the Health PlanKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

This CEO Is Disrupting The Insurance Industry With Tech & AI. “Never confuse effort for success”GuestTim Johnson (Founder & CEO)CompanyHealth In Tech, Inc. (Nasdaq: HIT)Websitehttps://healthintech.com/Tim's BioTim Johnson is the founder and CEO of Health In Tech. He has spent his entire career in the insurance industry, beginning on the property and casualty side at a small regional insurer before moving to larger firms including Liberty Mutual and AIG. He later transitioned to the brokerage side, working at leading brokerage firms where he built captives and developed alternative risk solutions.Mr. Johnson has over 30 years of experience as an entrepreneur and has founded multiple successful companies in the medical insurance sector. He has extensive knowledge in the stop-loss insurance and self-funded benefits space, and between 2005 and 2007, he helped pioneer some of the country's first Stop Loss captive programs for healthcare, applying proven techniques from the P&C world that had not previously been widely used in employee benefits. He also launched his own insurance carrier and built a vertically integrated platform offering underwriting, claims, repricing, and medical management services.Seeing how far behind healthcare was in technology, Tim began building Health In Tech with a system designed to help brokers quote and bind health plans more quickly and efficiently. That early tool ultimately evolved into the AI-powered platform Health In Tech is known for today.Company Bio:Health in Tech (“HIT”) is an insurance technology platform company, which offers a marketplace that aims to improve processes in the healthcare industry through vertical integration, process simplification, and automation. By removing friction and complexities, we streamline the underwriting, sales and service process for insurance companies, licensed brokers, and TPAs.Marketplace: We are a health insurance marketplace where insurance companies can list various stop-loss policy options for self-funded benefits plans. Licensed brokers registered on our platform can log in, upload certain required information, select policy plans, obtain a bindable quote and sell them to small businesses. Our technology enables us to medically underwrite insurance policies and usually produce bindable quotes within approximately two minutes, allowing us to deliver an integrated and seamless sales cycle.Customizable Solutions: Beyond policy underwriting and sales, our marketplace offers customization of health benefits plans, vendors, claims, and network services. Brokers can select customized plans that suit their customers.Accessibility and Savings: We make self-funded benefits plans and stop loss insurance accessible online for small businesses. We aim to deliver meaningful cost savings for low-risk, small employers with comparatively healthy employees through a digital medical underwriting process. We seek to deliver time savings for employers, brokers, TPAs, and carriers, by leveraging both external and internally developed technology.HIT was founded on the belief that self-funded benefits plans and stop loss insurance should be simple and streamlined with significant transparency. With over 30 years of industry experience of our management team, we understand the complexities of the healthcare insurance market, and we know how to integrate the multifaceted aspects of the industry. Our solutions and technology platforms do exactly this through vertical integration, process simplification, automation, and digitalization.

In this episode of Healthcare Happy Hour, David Saltzman sits down with Jennifer Berman, chief legal officer of Lumelight, to break down the key provisions of the Consolidated Appropriations Act (CAA) 2026. The discussion focuses on expanded transparency requirements, including new prescription drug reporting and significant changes to compensation disclosure rules impacting brokers, TPAs, and other health plan vendors. Jennifer also explores the growing fiduciary responsibilities for plan sponsors, increased litigation risk, and the need for structured governance and documentation. The conversation highlights both the challenges and opportunities these evolving regulations present for plan sponsors, vendors, and advisors.

In this episode of Head, Heart, and Boots, Brandon and I tackle a shift that many restoration companies are starting to feel but may not fully understand yet. The traditional flow of insurance work is changing. Claim volumes are tightening, TPAs are producing fewer opportunities, and customers are becoming more cautious about filing claims due to rising deductibles and policy pressure. That shift is forcing restoration companies to confront something the retail contracting world has been dealing with for decades: selling. We unpack what it means to operate more like a retail contractor and why learning to earn the customer's trust, present real numbers, and guide clients through decisions is becoming a core skill set for the industry. We talk through practical examples like offering financing, training teams to present rough order of magnitude estimates, using tools like Loom for better communication, and building a process that gives customers confidence before asking for their commitment. This conversation is less about tactics and more about mindset. The companies that embrace the shift toward proactive sales, better communication, and stronger client experience will be the ones that continue to win as the landscape evolves. Hope you enjoy. Chris Why You Should Listen [00:02:27] Why claim volumes and TPA lead flow are tightening and how insurance industry changes are forcing restoration companies to rethink their business model [00:04:49] How offering financing solutions can remove friction for customers and help companies close jobs that might otherwise disappear [00:07:10] What restoration companies can learn from retail contractors about selling, presenting estimates, and winning work in competitive environments [00:18:51] How better communication tools like Loom can dramatically improve customer trust and engagement during the sales and project process [00:23:39] Why the future of restoration will require teams that are skilled at relationships, persuasion, and customer experience rather than just task execution Did you know... Only 30% of businesses listed for sale actually find a buyer? Even more striking, just 10% of those sell for the price their owners anticipated or higher, meaning only 3% of all business owners achieve their desired sale price. By focusing on understanding and enhancing your enterprise value, you can significantly boost your chances of joining that successful 3%. Business Health & Value Assessment Start Assessment Know Your Enterprise Value. See Your Potential Gaps. Complete this assessment in less than 15 minutes and receive a free assessment for your business that includes: A Lite Valuation Of Your Business Your Value Multiplier Per Your Industry Health Assessment Per Our PYB Methodology Business Value & Growth Roadmap Tailored For You Value Acceleration Strategies Spotlight on Floodlight: Your Secret Weapon for Sales & Scaling This isn't a paid plug. It's real talk from the front lines. If you've ever thought, “How do I get a VP-level sales leader or even a sales team without hiring full-time?” Floodlight has the answer. Fractional Sales Leadership They act as your outsourced VP of Sales, taking full responsibility for training, managing, and growing your sales team. No six-figure hire needed. Clients often close 20 to 50 percent more deals within six months, thanks to data-driven coaching, CRM setup, scripts, and performance reviews.More at floodlightgrp.com/sales Commercial Sales MasterCourse A self-paced, video-driven B2B sales course designed specifically for restoration teams. Perfect for building commercial revenue and getting free from TPA handcuffs. Covers mindset, prospecting, pipeline building, LinkedIn lead generation, and includes a $250 discount with code SALESBOOST.Details at floodlightgrp.com/courses Tailored Consulting & Coaching Floodlight's Propel Your Business methodology offers a full-circle roadmap: financials, sales, marketing, leadership, recruiting, productivity. All built for contractors. These aren't “life coaches.” They're former restoration owners who've lived the chaos and know how to scale out of it.Explore more at floodlightgrp.com Live Training, Tools & Strategic Partnerships Floodlight also delivers live onsite and virtual training, keynote speaking, and leadership tracks covering operations, project management, and strategic growth. Bonus: They've vetted tools like Xcelerate, Liftify, and Sureti. Floodlight clients get access to exclusive discounts on tech that actually moves the needle.See all partnerships at floodlightgrp.com/partners Why it matters for you as a listener You don't need to figure this stuff out alone. If you're serious about sales growth, operational clarity, exit readiness, or leadership development, Floodlight is already helping folks like you scale smarter. And you get it from industry insiders. People who've sat in your chair, survived the fires, and built systems that actually work.

"We don't view ourselves as a TPA, we view ourselves more as a platform... our goal is to simplify and reduce the barriers of entry into the TPA space."The role of the Third-Party Administrator is undergoing a massive evolution. No longer just a back-office claims processor, the modern TPA is being asked to serve as the high-tech, high-touch "nucleus" of the entire health plan.My guest this week is Vinny Esposito, CEO of Reflect Health (formerly S&S Health). Drawing on a decade of experience in the hedge fund world, Vinny recognized a massive opportunity to bring scalable, asset-light infrastructure to the self-funded market. Today, Reflect Health acts almost like the "Intel Inside" of the industry, licensing its proprietary claims technology to other TPAs and health plans.In this episode, we explore exactly what it takes to build the TPA of the future. We discuss how to solve "point solution fatigue" through a centralized marketplace, the mechanics behind infusion drug carve-outs, and how to successfully deploy dynamic deductibles to incentivize better care routing. Vinny also shares his bold vision for "frictionless claims" paid instantly at the point of service, moving us closer to an Amazon-style shopping experience for healthcare.If you want to understand the technological and administrative innovations driving the self-funded market forward, this episode provides the blueprint.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Competing on Service in the TPA Market (00:01:56) Meet Vinny Esposito & Reflect Health (00:03:35) Rebranding from S&S Health (00:07:32) From Hedge Funds to Healthcare Disruption (00:11:05) The Platform Model: Licensing Tech to Other TPAs (00:15:05) The Marketplace & Infusion Drug Carve-Outs (00:19:14) How the TPA Role is Expanding (The "Nucleus") (00:24:12) Direct Contracting, RBP, and DPC Integration (00:29:15) Dynamic Deductibles & Tiered Networks (00:33:25) Curing "Point Solution Fatigue" (00:41:09) The Future of Stop-Loss and Preventative Care (00:45:44) The Fiduciary Breaking Point & 80% Renewals (00:50:26) Frictionless Claims & Amazon-Style HealthcareKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"We don't view ourselves as a TPA, we view ourselves more as a platform... our goal is to simplify and reduce the barriers of entry into the TPA space."The role of the Third-Party Administrator is undergoing a massive evolution. No longer just a back-office claims processor, the modern TPA is being asked to serve as the high-tech, high-touch "nucleus" of the entire health plan.My guest this week is Vinny Esposito, CEO of Reflect Health (formerly S&S Health). Drawing on a decade of experience in the hedge fund world, Vinny recognized a massive opportunity to bring scalable, asset-light infrastructure to the self-funded market. Today, Reflect Health acts almost like the "Intel Inside" of the industry, licensing its proprietary claims technology to other TPAs and health plans.In this episode, we explore exactly what it takes to build the TPA of the future. We discuss how to solve "point solution fatigue" through a centralized marketplace, the mechanics behind infusion drug carve-outs, and how to successfully deploy dynamic deductibles to incentivize better care routing. Vinny also shares his bold vision for "frictionless claims" paid instantly at the point of service, moving us closer to an Amazon-style shopping experience for healthcare.If you want to understand the technological and administrative innovations driving the self-funded market forward, this episode provides the blueprint.Thank you to our 2026 sponsors!ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com to learn more.Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.Chapters:(00:00:00) Intro: Competing on Service in the TPA Market (00:01:56) Meet Vinny Esposito & Reflect Health (00:03:35) Rebranding from S&S Health (00:07:32) From Hedge Funds to Healthcare Disruption (00:11:05) The Platform Model: Licensing Tech to Other TPAs (00:15:05) The Marketplace & Infusion Drug Carve-Outs (00:19:14) How the TPA Role is Expanding (The "Nucleus") (00:24:12) Direct Contracting, RBP, and DPC Integration (00:29:15) Dynamic Deductibles & Tiered Networks (00:33:25) Curing "Point Solution Fatigue" (00:41:09) The Future of Stop-Loss and Preventative Care (00:45:44) The Fiduciary Breaking Point & 80% Renewals (00:50:26) Frictionless Claims & Amazon-Style HealthcareKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

In this episode, Lauren Lewis visits ACSI and sits down with James Brand, President, and Kristen Huffcut, Senior Relationship Manager, to discuss the complexities of retirement plans and why many employers struggle to manage them. ACSI is a third-party administrator (TPA) specializing in retirement plan compliance, administration, and support for small and mid-sized businesses. Their team helps companies navigate the legal, operational, and regulatory requirements behind retirement plans so business owners can focus on running their organizations. Lauren, James, and Kristen discuss: What a Third-Party Administrator (TPA) actually does Why retirement plans are becoming more complex The impact of legislation like Secure 2.0 and New York Secure Choice Why many companies run into compliance problems The role of TPAs in fixing plan issues and avoiding costly penalties Why local expertise and real relationships matter in retirement planning How retirement benefits help companies attract and retain talent The importance of proactive guidance instead of reactive problem-solving James also shares his unique career journey, from working in finance in New York City, to returning to Buffalo and eventually becoming President of ACSI. Kristen explains how her experience working with retirement plans from the advisor side led her to join the ACSI team and help businesses deliver a true white-glove service experience to their employees. If you're a business owner, HR professional, or financial advisor navigating retirement plan compliance and employee benefits, this episode breaks down the pain points behind retirement planning and how to solve them. 

Ary Rosenbaum talks about major misconceptions that plan sponsors have about 401(k) TPAs.

Melissa Torito and Kacen Lawson are back to provide the "how-to" on staying protected. In this episode of The Sentinel Show, they dive deep into the world of Investment Committees—demystifying what they are, why they exist, and how to build one that actually adds value to your retirement plan.Whether you are managing a five-person startup or a $100 million plan, the hosts break down the practical logistics of plan oversight. From the "magic" of odd numbers in committee sizing to the critical importance of looking beyond the C-suite for members, Melissa and Kacen share expert insights on keeping your plan compliant and your participants happy.Key highlights include:The Ideal Size: Why three to five members is the "sweet spot" for most small to mid-sized firms.The "Document or it Didn't Happen" Rule: Why meeting minutes are your best defense during an IRS or Department of Labor audit.Beyond Leadership: The benefits of including trusted employees and subject matter experts to get a diverse perspective on plan performance.Fee Monitoring: How active oversight—not just picking the "cheapest" option—prevents the lawsuits that plague unmonitored plans.Thresholds for Change: Identifying the participant counts and asset sizes that warrant a fully formed, formal committee.Don't let your retirement plan fall into the "set it and forget it" trap. Tune in to learn how to lean on your TPAs and advisors to build a committee that stands up to scrutiny.

Eric Dyson, Executive Director of 90 North Consulting and one of the retirement industry's more active ERISA expert witnesses, joins the 401(k) Specialist Podcast for a practical conversation on how plan sponsors and advisors can reduce fiduciary risk—and be better prepared if the Department of Labor comes calling.Drawing on his experience testifying in more than a dozen ERISA cases, Dyson shares the most common mistakes he sees in litigation and investigations, why a DOL audit may be a bigger risk than a lawsuit for most plans, and what courts actually expect from fiduciaries. He tackles pressing questions around paying advisors and TPAs with plan assets, properly documenting QDIA selections to secure safe harbor protection, conducting RFPs and benchmarking at “reasonable intervals,” and crafting committee meeting minutes that protect rather than expose.Dyson also provides clear, actionable steps sponsors can take before their next committee meeting to strengthen governance, document prudence, and stay off the litigation radar, and reduce fiduciary risk.EDITOR'S NOTE: This podcast episode is part of our new “Deep Dive” special content package for Q1 2026 titled, “How Not to Get Sued.” You can find additional coverage in the links below, and more focused content will be available in the coming days.SEE ALSO:How Not to Get Sued in 2026: Part 1How Not to Get Sued 2026: Part 2

On this episode of Astonishing Healthcare, Judi Health's Mike Tate (VP, National Business Development) and Mark Pearce (Director, TPA Operations) join us in the studio to discuss the role of Third-Party Administrators (TPAs) in the self-funded employer market. As Mike explains, TPAs act as the "enforcers" of an employer's plan document, responsible for pulling everything together and ensuring claims accuracy, network access, and financial stewardship. Mark dives into the distinction between carrier-owned (ASO) and independent TPAs, explaining how independent models offer greater flexibility in plan design. And of course, they highlight a significant industry challenge: legacy technology. Many administrators rely on antiquated systems that limit customization and data visibility. In contrast, modern platforms empower plan sponsors to integrate point solutions effectively, customize networks for high-value care (e.g., through centers of excellence), and drive better member engagement. If you've ever asked yourself, "What does a TPA really do?" or "Should I look at different TPAs?" this episode will be worth your time to listen to.Ultimately, successful healthcare administration relies on managing "hundreds of little things" correctly for each benefit (Rx, medical, vision, and dental) - from provider payments to member support. That's how you create positive financial and clinical outcomes. Related ContentAH080 - Health Benefits 101: The Importance of "Smart" Care Navigation, with Andy KageleiryReplay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better OutcomesAH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmDJudi Health™ Earns Best Healthcare InsurTech Solution in the 9th Annual MedTech Breakthrough Awards ProgramFor more information about Judi Health and this episode, please visit Judi Health - Insights.

Sunstone Health CEO Joshua Resnikoff joins Chris Lustrino to explain how Sunstone uses AI on healthcare claims data to proactively identify children with developmental delay—starting with epilepsy and autism—and help families reach the right specialists and diagnostics faster.They break down what claims data is, why the healthcare system is reactive by default, and how Sunstone's approach can compress what often takes years into roughly weeks by flagging high-need cases, coordinating advanced diagnostics, and delivering actionable next steps. Joshua also shares Sunstone's go-to-market strategy (positioned as an employer-paid benefit), why the pricing model is designed to reduce “point-solution bloat,” and how expansion could move across employers, TPAs, reinsurers, and large insurers. 00:00 Needle-in-a-haystack intro03:13 What Sunstone does (AI + claims data)05:32 Flagging patients vs. diagnosing07:21 Employer benefit + privacy model15:54 GTM + sales cycle reality17:57 Outcome-based pricing model20:16 Unit economics ($10k per case)22:11 Expansion paths + other diseases26:23 Fundraise use of proceeds28:03 Investor closing

What exactly is a TPA (Third-Party Administrator)—and why does it matter in the world of health insurance?In this episode, Nick Buratti from Allied Benefit Systems joins me for a clear, practical conversation about how TPAs operate, what they're responsible for, and where they fit into the broader health insurance ecosystem. If you're involved in employee benefits, self-funded health plans, or just want to better understand how all the moving pieces connect, this episode is a must-watch. #TheHITPodcast #HealthInsurance #TPA #EmployeeBenefits #SelfFunded #HRLeadership #AlliedBenefitSystems #HealthcareExplained

In this installment of The Phia Group's “Empowering Plans” podcast, attorneys Bryan Dunton and Cindy Merrell discuss what happens when laws evolve faster than contracts, and how many compliance failures live in old documents. This episode breaks down how legacy contract language creates modern risk under HIPAA Part 2 and emerging PBM transparency reforms, particularly where downstream data sharing and compensation disclosures are involved. Brokers, TPAs, and plan fiduciaries will want to tune in and find out how these changes will impact their groups.

Send us a textSchedule an Rx AssessmentWith Medicare's Maximum Fair Price (MFP) rebates officially underway and the 340B rebate mechanism on hold, pharmacy owners are left navigating one of the grayest areas the industry has seen in years.In this episode, Scotty Sykes, CPA, CFP®, Bonnie Bond, CPA, MBA, and Austin Murray sit down with Julie Crozier, CEO at  @secure340b to unpack how MDPNP is colliding with 340B and what pharmacies should be paying attention to right now.We cover:How MDPNP and MFP rebates are flowing todayThe duplicate discount problem no one is reconcilingBeacon's role and why future reconciliation risk mattersDispensing fee pressure, CE relationships, and contract implicationsPractical considerations if TPAs or covered entities push for carve-outsAnd more!More About Our Guest:As CEO of Secure340B, Julie is responsible for formulating and executing strategic plans and technology to deliver critical and timely intel to 340B stakeholders. Julie has over 25 years of pharmacy experience including co-founding, growing and leading a pharmacy software company, Macro Helix, which was acquired by McKesson Corp (NYSE: MCK) in 2012. Julie also has experience in retail pharmacy, long-term care, state Medicaid programs and healthcare revenue cycle. She holds a Bachelor's in Pharmacy and a Master's in Pharmacy Administration from The University of Texas at Austin.Julie serves on the board at Crossroads Community Services, a food pantry, and lives in Dallas, Texas with her husband and 2 daughters.Stay connected with Julie and Secure340B: Julie Crozier LinkedInSecure340B WebsiteSecure340B FacebookSecure340B LinkedInSecure340B InstagramStay connected with us: FacebookYouTube LinkedInInstagramMore resources on this topic: Podcast - Driving Independent Pharmacy Profitability in 2026Podcast – The Startup Compounding Pharmacy PlaybookPodcast – Inside the Fight for Compounding: Advocacy, Growth, and Regulation

In Episode 498, host Stacey Richter converses with Mark Noel of ClaimInsight about the critical aspects of payment integrity within self-insured employers and plan sponsors, focusing on the arms race with revenue cycle management (RCM).  The discussion reveals three main insights: the substantial impact of small claim errors, the inherent flaws and conflicts within prepayment analysis by TPAs, and the problematic financial incentives influencing claim processing. Noel emphasizes the importance of prepayment integrity for both plan savings and protecting members, underscoring the need for meticulous oversight and proactive management in payment processes. === LINKS ===

In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Brian O'Hara share the latest information TPAs and employer plan sponsors need to know about the No Surprises Act. The discussion focuses on recent federal guidance, updated arbitration data, key court decisions affecting NSA enforcement, and practical takeaways for managing provider billing disputes and controlling plan exposure in 2026.

On this special preview episode of Voices of Self Funding, co-host Tom Testa sits down with Ron Peck, Chief Legal Officer at The Phia Group, to discuss his highly anticipated session at Executive Forum 2026: “Fiduciary Gotchas and the Company You Keep.” From revenue-sharing arrangements to PBM contracts and vendor disclosures, Ron shares what TPAs need to know now as courts and regulators sharpen their focus on fiduciary responsibilities. With plaintiff attorneys getting more creative and DOL audits on the rise, this conversation is a must-listen for anyone looking to protect their business and stay compliant. Catch the full session live at Executive Forum 2026 — register today to reserve your seat and join the industry's most important conversations. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

On this episode of Voices of Self-Funding, host Tom Testa speaks with MIT-trained AI researcher and ClarityCare AI co-founder Hermine Tranie about how artificial intelligence is delivering measurable wins in utilization management (UM) and prior authorization (PA). Hermine explains how AI agents convert unstructured records into structured insights, drive real-time approvals at the point of care, and free up nurses for higher-value tasks – boosting accuracy, efficiency, and compliance. As a preview to her interactive “AI Mini-Hackathon” session at HCAA's 2026 Executive Forum, Hermine shares a practical roadmap for adoption and what TPAs and self-funded employers can do today to start seeing ROI. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

We revisit how PPOs got built on discounts and show why total value beats sticker price. Scott Smith joins us to explain nationally curated high-performance networks that rank providers on effectiveness, appropriateness, and cost, and how that changes renewals, member experience, and fiduciary risk.• why traditional PPO discounts miss total cost of care• how consolidation and narrow networks increase abrasion• claims-based scoring at the provider NPI level• quality metrics that matter: effectiveness, appropriateness, cost• member tools: stars, plain-language summaries, mobile access• plan design that waives cost sharing for high-quality choices• PEPM pricing without shared savings games• national footprint for TPAs and large employers• faster ROI and improved MLR through reduced waste• roadmap to a true BUCA alternativeThis episode is sponsored by Benepower, the platform of choice for a modern benefits experience. Benepower is an AI-powered benefits platform offering access to top products and services, enabling consultants and employers to create customized plans, optimize usage, and measure effectiveness. www.benepower.com

On this episode, host Adam Russo welcomes Andy Willoughby, Founder, Willow Hill Consulting, a company that helps self-funded employers, third-party administrators (TPAs), and vendor partners solve high-impact challenges and drive real results. Andy shares insights on the importance of focusing on effective strategies rather than buzzwords in healthcare cost containment. They also discuss healthcare enrollment, insurance literacy, and the challenges of understanding health plans. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

Guests: Jason Burg – 40-year industry veteran, retired GC, national MRP consultant Jim Greer – 40+ years in B2B consulting, national carrier & vendor network strategist Jason Burg: 407-782-1772 This episode explores why MRP (Managed Repair Programs) and DRP (Direct Repair Programs) are becoming essential revenue streams for roofing contractors—and why the traditional door-to-door storm model is becoming increasingly unstable. The discussion breaks down how shifting insurance policies, rising deductibles, declining storm frequency, ACV-only policies, and market restrictions are changing the economics of storm restoration roofing. The episode explains how MRPs, DRPs, TPAs, and MGAs actually work, why most contractors misunderstand them, and how these programs create recurring, predictable revenue while improving business valuation. It details why door-to-door alone has become feast-or-famine, why free roofs are disappearing, how contractors can still achieve 35–40% margins through the right programs, and why insurance carriers urgently need more vetted roofers—especially during CAT events and daily claims. The episode also clarifies misconceptions around low margins, lack of control, and qualification barriers, outlining how background checks, onboarding, and vendor approvals actually work. Real-world examples show contractors getting approved within days when introduced through the right relationships. Ultimately, this episode provides a blueprint for shifting from a volatile storm-chasing model to a sustainable, diversified revenue system built on direct carrier work, recurring repair opportunities, and long-term business stability.

We revisit the rising problem of the “functionally uninsured” and ask how to restore real access for employees who delay care because of confusion and cost. Paymedix CEO Tom Policelli shares how a super EOB, upfront provider payment, and 0% financing change behavior and bend trend.• confusion outranking cost as the top barrier to care• hospitals pushing prepayment and the access wall it creates• income-tier patterns driving ER and inpatient overuse• super EOB mechanics and single monthly reconciliation• provider payment upfront and revenue-cycle relief• employer savings of two to three trend points annually• advisor positioning and retention benefits• partnerships with EXO Health to improve network economics• TempoPay for pharmacy access and first-dollar fills• risk management via broad pooling and automatic eligibility• national expansion through aligned partners and TPAs• a third path beyond prepay or bill-and-pray collections“Go to PayMedix.com.”This episode is sponsored by Benepower, the platform of choice for a modern benefits experience. Benepower is an AI-powered benefits platform offering access to top products and services, enabling consultants and employers to create customized plans, optimize usage, and measure effectiveness. www.benepower.com

"Success leaves clues. And sometimes that clue is healthy leadership that is just able to take them from plateau to plateau." - Trey MarinelloMy guest this week, Trey Marinello of Houlihan Lokey, is an expert in a topic everyone is constantly talking about: Private Equity. Trey joined the show to demystify the world of investment banking and explain exactly why private equity firms are pouring billions of dollars into the employer-sponsored healthcare space.Trey breaks down the current trends, explaining why PE isn't just about leverage and debt, but about "turning the propeller faster" through distribution expertise and strategic growth. We discuss why categories like TPAs, cost containment, and innovative funding models are red-hot, while "wellness" and "population health" have struggled to prove their ROI.We also explore the potential of AI to revolutionize mental health care, why “ICHRA” is still a wild card, and how smart brokers are becoming essential value-drivers in M&A deals.Tune in for a masterclass on following the money in healthcare!Chapters:(00:00:00) Why Private Equity is Pouring Billions Into Employer Healthcare(00:00:35) Why Private Equity Loves Healthcare (00:08:59) What Does an Investment Banker Actually Do? (00:17:25) How PE Firms Use Distribution to Scale (00:20:06) Is ICHRA the Future or a Fad? (00:28:50) The Rise of Alternative Funding (00:42:34) Why "Wellness" Investments Failed (00:57:16) How Brokers Drive Enterprise Value (01:02:47) The Hottest Category in Healthcare M&AKey Links for Social:@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFundedListen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

On this episode of Voices of Self-Funding, host Ramesh Kumar welcomes Lee Lewis, Chief Strategy Officer at the Health Transformation Alliance and host of the Broken Benefits podcast. Together, they explore how some of the nation's largest employers are reshaping healthcare — and what smaller self-funded employers and TPAs can learn from their playbook. Lee introduces his “ABC” framework: Advanced Primary Care, Behavioral Health, and Centers of Excellence. They dive into why direct primary care is gaining traction, how advanced behavioral therapies like TMS and ketamine can unlock cost-effective mental health care, and why Centers of Excellence and tiered networks are becoming essential levers for better outcomes at lower cost. From strategies to supplement traditional networks to practical steps TPAs can take to differentiate and deliver value, this is a powerful conversation packed with actionable insights for anyone rethinking healthcare benefits in a self-funded world. Registration is now open for HCAA's Executive Forum 2026, where conversations like this continue live. Learn more at HCAA.org. This episode was sponsored by WLT Software. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

On this episode, host Adam Russo welcomes John Farnsley, EVP Business Development at 90 Degree Benefits, a company that is humanizing healthcare by providing plans that increase savings without sacrificing high-quality care. John shares insights on the evolution of healthcare delivery and the changing role of TPAs in the industry. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

In this episode, Rob Beller and Lee Boyd are joined by Michael Balarezo, Founder & CEO of Adjusto, for an in-depth discussion about the complexities and opportunities in contents claims. Michael recounts Adjusto's founding story, rooted in his own experiences both as an adjuster and as a policyholder impacted by catastrophe. The conversation explores how Adjusto's platform was purpose-built with artificial intelligence at its foundation to address longstanding inefficiencies for both policyholders and adjusters. Key themes include the adaptive use of machine learning and data science for multi-format input (written, CSV, and photo data), transparent and fair valuation practices, and integrations that streamline industry workflows. Michael details the patent-pending "FairMatch" system, the importance of personalized service in contents claims, and the role of technology partnerships across the insurance ecosystem. Key Highlights Adjusto was founded to address persistent pain points in contents claims, informed by Michael's background as both an adjuster and a policyholder affected by large-scale property loss. The platform is built from the ground up with AI and machine learning, enabling sophisticated handling of written lists, CSV uploads, and photographs for contents documentation. Adjusto's architecture enables real-time data processing and transparent interactions for both adjusters and policyholders, simplifying the experience and supporting trust in claim outcomes. The FairMatch algorithm—patent-pending—combines expert adjuster logic with data from consumer sources to generate accurate, fair valuations recognized by both insurers and policyholders. The solution serves carriers, TPAs, independent adjusting firms, and content specialists, and can be deployed as a standalone tool or integrated into existing claims environments. Adjusto integrates with platforms such as Snapsheet, participates in the Guidewire Vanguard Program, and is actively pursuing integration with Verisk marketplace. Michael discusses how dissatisfaction with contents claims can lead to policyholder churn, underscoring the need for tailored, data-driven processes in personal property claims.

In Episode 491, Stacey Richter interviews Elizabeth Mitchell, CEO of the Purchaser's Business Group on Health (PBGH), about the PBGH Transparency Demonstration Project. They discuss the project's aim to provide jumbo self-insured employers with transparency in healthcare costs, quality, and safety data. Collaborating with Milliman and Embold and funded by the Peterson Center on Healthcare, PBGH's project reveals no correlation between higher prices and quality in healthcare services. The episode highlights the impacts on TPAs, consultants, and clinical organizations, and underscores the importance of employers using this new transparency data for strategic advantage and compliance with the Consolidated Appropriations Act. Richter and Mitchell delve into the broader implications for creating high-value networks and fostering market competition based on quality and affordability. === LINKS ===

On this episode of Voices of Self-Funding, host Ramesh Kumar welcomes Arun Santhebennur, Co-founder and CEO of Voicegain, to explore how voice AI is reshaping healthcare operations for TPAs, payers, and health plans. They tackle the tough truth that 95% of AI pilots fail, unpacking why — from hype and skill gaps to the “build vs. buy” dilemma and change management challenges. More importantly, they share where AI is already succeeding: automating claims status calls, streamlining utilization management, and making complex health plan information accessible to members. Listeners will hear a roadmap for launching successful AI pilots — starting with proven use cases, aligning incentives, and using AI to augment (not replace) people. It's a forward-looking conversation on turning AI from a risky experiment into a real value driver. This episode was sponsored by WLT Software. For more information, visit HCAA.org. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

If you are listening to this prior to October 9, 2025, go to the 32BJ Changing the Playbook on Hospital Prices event, where Mark Cuban will be keynoting. Cora Opsahl will also be speaking, and I will be there listening. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. So, trust, simplicity, and a chicken. Yeah, this is where this whole conversation with Mark Cuban and Cora Opsahl winds up. And it is a barnstormer because you know what some really good advice is for anybody trying to do right by patients and taxpayers and plan sponsors? It will take trust. It will take making the complicated as simple as possible. And also if you could pay with a chicken, like in the good old days, that would be messy—I can say with confidence, having grown up in Pennsylvania Dutch country, where there are many, many chickens—but also being able to pay with a chicken could also indicate that healthcare prices are reasonably chicken proportionate and that the doctor-patient relationship is good enough to break bread (or have chicken). That last part is really important, and Cora Opsahl says this at one point in the episode that follows. It doesn't matter how wonderful the transparency or the financing. If the prices are insane and there's no more reasonably priced options in any given market, then yeah. Shane Cerone says in an upcoming show, he says, “We do not have a broken healthcare market. We do not have a healthcare market. There is no market.” Okay … so, you could call this conversation a continuation of the episode with Ann Kempski (EP444), entitled “Two State Healthcare Laws Often Don't Go as Planned.” But it's not just healthcare laws that often don't go as planned. It's some very foundational constructs that we have built the healthcare sector upon that may also not go as planned. The healthcare sector is like a game of pachinko. You chuck an input into the mix, and it will bounce all around into all the perverse incentives and human beings and the non-market that we have. And who the heck knows what is gonna pop out the other side? It's like game theory at its most unpredictable. So, in healthcare, there are many, many examples of when the solution to a problem arguably creates worse problems than the problems the solution was trying to solve for. But we—Mark Cuban, Cora Opsahl, and I—are gonna shake our fists at two such solutions today: high deductible health plans (or just high deductibles in general) and then self-insured employers trying to solve the complexity of the healthcare industry by hiring consultants and middlemen, middle people, and other vendors to navigate the pachinko parlor (that is, our $4.9 trillion healthcare sector) on their behalf. Now, I am not in any way saying the spirit of these two endeavors—high deductibles and hiring consultants and middlemen—weren't wholehearted. They seem just like many other well-intentioned solutions: very logical on their face. What I am saying is there are many ways in the real world for even the most, again, genuine endeavor to turn into a money grab for those so inclined. While at the same time I'm saying all this, I'm also very much saying that there are some amazing consultants and middle folks such as independent third-party administrators, otherwise known as TPAs, and PBMs (pharmacy benefit managers) who are transparent and hold themselves accountable to the fiduciary responsibilities that their clients are held to in real terms—not just in marketing speak with 40 pages of disclaimers following. There are great folks out there, many of whom listen to this podcast and are part of our tribe on the regular. And to you, I say thank you for being here, because it takes all the knowledge and more from every one of the guests featured in these past 487 Relentless Health Value episodes plus treating every day like a school day to make sure that we all are not getting shanked from behind by some innocent-looking contract term that turns out to be anything but. The conversation that follows starts out talking about high deductibles; naturally segues into how third-party intermediaries can actually exacerbate the issues here; then we get into transparency, financing, clinical organizations taking on risk, and the benefits and challenges of direct contracts; then Mark lays out a vision for the future. Okay … I wanna get to this conversation. If you are a new listener here—and you might be because … yeah, Mark Cuban—let me just inform you that this podcast is largely listened to by those who work in the healthcare industry. So, you are going to encounter acronyms. You will also encounter me referencing earlier episodes because surveys say listeners really appreciate these callbacks to go get additional information about any given topic. You can get what amounts to a personalized Master's of Healthcare Administration curriculum if you follow the episode threads long enough. And that was a direct quote from a listener. About the acronyms: They are holy terrors, and we in the healthcare industry are chock-full of them. See the list of acronyms that come up so that you can follow along at home if this is your first day at our rodeo. Also in the show notes is a transcript of this show, along with links to all of the mentioned episodes. Okay … here's my conversation with Mark Cuban, who is Mark Cuban and also CEO and founder of Mark Cuban Cost Plus Drugs. Also, we have Cora Opsahl, who is health fund director of the 32BJ Health Fund and an expert in many things healthcare. Also mentioned in this episode are Shane Cerone; Ann Kempski; Mark Cuban Cost Plus Drugs; 32BJ Health Fund; Preston Alexander; Stanley Schwartz, MD; Elizabeth Mitchell; Kimberly Carleson; Andreas Mang; Jonathan Baran; Claire Brockbank; Dave Chase; Cristin Dickerson, MD; Green Imaging; Kevin Lyons; and Vivian Ho, PhD.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   Mark Cuban, a native of Pittsburgh, PA; a graduate of Indiana University; and now a Dallas, TX, resident, has always been an entrepreneur. From selling and trading baseball cards, selling garbage bags and magazines door-to-door, to starting a business buying and selling stamps at age 16, there have been few years in his life when he wasn't starting or running a business. He got a job at one of Dallas's first retail software stores, Your Business Software. He spent nine months doing everything from learning how to code, supporting and installing every type of business software, and of course, making sure the store opened on time. That went well until he made the executive decision to turn over the store opening duties to a peer so he could pick up a check for a sale. He was fired. Mark decided it was time to start on his own. The next day, MicroSolutions was founded. Over the next seven years, MicroSolutions became a national leader in Systems Integration and custom applications for local and wide area networks. Growing to 80 employees, never having a losing month of operations and nearly $36M in annualized sales, in 1990, MicroSolutions was sold to CompuServe. At that point Mark “retired” to investing in public and private companies. His knowledge of the networking industry led to success and brought returns of 80% and more each year. Mark purchased the Dallas Mavericks for $285M. The Mavs would have the second-best record in the NBA during his ownership tenure. Mark sold majority control of the Mavs in 2023 but continues to be actively involved with the team. He first appeared as a “Shark” on ABC's Emmy Award–winning hit business show Shark Tank in 2011 and quickly established himself as one of the most popular and tough Sharks, investing millions of dollars in hundreds of small businesses. He's been nominated nine times for an Emmy for Shark Tank. His last appearance on the program was during season 16 in May 2025. In 2019, Mark co-founded costplusdrugs.com. Its launch on January 19, 2022, with transparent pricing and a limited markup, has fundamentally changed the pricing of medications in the United States. Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of SEIU 32BJ have easy and sustained access to affordable, high-quality healthcare. Cora has prioritized a data-driven approach, focusing on reducing trend, solving the affordability challenge on behalf of union members, and, most important, keeping members at the center of every decision. Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. In 2024, Cora conducted an innovative medical request for proposal, stipulating that all finalists have a signature-ready contract drafted by the 32BJ Health Fund prior to award. As a result, the Fund negotiated an agreement that brought unprecedented visibility and increased accountability to its benefit. In 2025, the Health Fund is focused on direct-contracting opportunities that allow it to carve out key benefits and ensure quality while managing spend. Cora is regarded as an expert in pharmacy benefit management and was recently appointed to the Board of Governors for the National Alliance for Healthcare Purchaser Coalitions and the Purchaser Advisory Council for the National Quality Forum and Joint Commission. She previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations, strategy, and acquisitions. Cora earned an MBA from Saint Louis University.   06:25 What was the original rationale behind high deductibles? 07:38 How high deductibles are creating a class of functionally uninsured people. 09:29 EP482 with Preston Alexander. 10:20 “We're using health insurance as a proxy for healthcare.” —Mark 12:30 How providers are now in the debt collecting business rather than the healthcare business. 12:55 EP486 with Stan Schwartz, MD. 15:16 “We have a fundamental reasonability problem.” —Cora 16:07 EP425 with Marshall Allen. 18:25 Direct contracting versus self-funded employers. 19:27 EP436 with Elizabeth Mitchell. 19:30 EP480 with Kimberly Carleson. 19:33 EP372 with Cora Opsahl. 23:53 Why the current system doesn't allow the accountability that is needed. 24:39 EP452 with Cora Opsahl. 26:34 How direct contracting gives strength back to independent practices that high deductible plans take away. 27:46 Who pays, what's the price, and where does the power lie? 31:24 EP419 with Andreas Mang. 34:45 How it comes down to power and leverage when controlling healthcare costs. 38:13 EP483 (Part 1 and Part 2) with Jonathan Baran. 38:35 Why putting together a network and just buying healthcare—not discounts—is not as difficult as it seems. 40:10 Why we need to stop talking about disruption and start talking about change. 40:56 EP453 with Claire Brockbank. 41:02 EP484 with Dave Chase. 43:07 EP485 with Cristin Dickerson, MD. 44:32 EP487 (Part 1) with Kevin Lyons. 46:34 EP466 with Vivian Ho, PhD. 47:40 Why it's the incentives that are different between American hospitals and hospitals in a single-payer program. 50:25 The main takeaways from the conversation. 51:08 Why you can't fix the problems in healthcare without transparency.   You can learn more at markcubancompanies.com and costplusdrugs.com and follow Mark on LinkedIn, Bluesky, Threads, and X. You can follow Cora on LinkedIn.   @mcuban of @costplusdrugs and Cora Opsahl discuss trust and simplicity in #healthcare on our #healthcarepodcast. #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Kevin Lyons (Part 2), Kevin Lyons (Part 1), Dr Stan Schwartz (EP486), Dr Cristin Dickerson, Elizabeth Mitchell (Take Two: EP436), Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander

In episode 485, Stacey Richter interviews Dr. Cristin Dickerson on the topic of direct contracting for imaging services. They discuss the high costs of imaging, which can account for 6-11% of a plan sponsor's healthcare spend. The episode covers the potential for significant cost savings and improved patient access through direct contracting, bypassing traditional TPAs that may have conflicts of interest or contractual constraints.  Dr. Dickerson, who is the founding partner of Green Imaging, explains how her organization has successfully implemented direct contracting, providing affordable and high-quality imaging services nationwide. They also address common barriers such as complexity in coding and payment processes, the reluctance of TPAs, and the habitual referral to 'down the hall' services. The conversation highlights the importance of price transparency, patient education, and how Green Imaging supports plan sponsors in navigating these challenges. === LINKS ===

Right up front here, let me just state loudly that there are some amazing independent TPAs (third-party administrators) out there who have the expertise, the scrappy willfulness, and the deep desire to do right by their clients, their self-insured employer clients. For a full transcript of this episode, click here. If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe. And look, they may be facing some of the same headwinds that plan sponsors themselves face, like anticompetitive contracts, brokers who are up to no good, etc. So, just keep that in mind as you listen. And the main point of all of this if you are a plan sponsor is, find a good TPA partner, which, as Bryce Platt has said about consultants but same rules apply about TPAs here, the difficulty is being informed enough to tell the difference. So, the goal of this show is to help with that, the “be informed enough to tell the difference.” All of this being said, this is technically a Take Two; but we trimmed it down and welcome to a whole new intro. So, call this a refresher and an update about a really, really important topic from last year that is becoming extremely (maybe even more) relevant this year. Really relevant. Consider, for example, the show with Claire Brockbank (EP453) about carrier/TPA RFPs (requests for proposal) and all of the landmines that are really expensive, that are buried in some of these contracts. Then there was the Cynthia Fisher show (EP457) from last year about the millions, maybe billions of dollars in aggregate going missing in medical (ie, TPA or ASO [administrative services only]) spread pricing. We had “The Mystery of the Weekly Claims Wire” show with Justin Leader (EP433), again, revealing money that's being disappeared when the TPA is withdrawing dollars from plan sponsor checking accounts. And then there's the payment integrity episode with Kimberly Carleson (EP480) from a few weeks ago with just another wrinkle on this, namely TPAs or ASOs who insist on auditing themselves and how that turns out for members and plan sponsors. Oh, and last, but certainly not least, is the whistleblower show with Ann Lewandowski (EP476) on how a TPA arm of an EBC (employee benefit consultant) allegedly pocketed $20 million—$20 million of their client's pharma rebates—and used that $20 million to fund their executive bonus pool. What a time to be alive! All of this just highlights the huge stakes for plan sponsors to really understand what their TPA is all about. And when I say high stakes, I mean from both a legal standpoint and also just vast dollars in play here. But this episode with Elizabeth Mitchell is also, I'm gonna say, extremely relevant given just a few ripped from the headlines and news articles such as these. I'm gonna start actually with a post from Kimberly Carleson, and I like the comment by Jeff Evans, who wrote, “How does $8,710 equal $104,266?” Spoiler alert, it doesn't. Lots of missing dollars there. Someone's hands are in the cookie jar. Oh, look, the TPA has entered the chat. In a nutshell, and I'm quoting something Peter Hayes wrote, he wrote, “TPAs have received relatively little public attention. [There's an article in Health Affairs] that describes how TPAs impose hidden fees, benefit from their own form of spread pricing, and otherwise prioritize their own financial interests over those of their plan clients.” Also, here's a totally other issue. Let me quote Luke Prettol highlighting something Jason Shafrin had written about a paper by Jeff Marr, Daniel Polsky, and Mark Meiselbach. Let me slightly rephrase what Luke said. He wrote, “Employers pay, on average, a 4.7% [so almost 5%] price markup when hospitals are in their TPA's [Medicare Advantage] network.” Right? Dr. Eric Bricker talked about this in that episode (EP472) just how TPAs with MA (Medicare Advantage) business negotiate their commercial clients to pay higher rates so that then they can pay lower rates for their own MA members. As Luke wrote, “On its face, this overpayment does not appear to be solely in the interest of participants.” No kidding. Now, let's spin the wheel here. There are barriers for TPAs themselves, even the ones who have a deep desire to do the right thing. As Patrick Moore wrote, “Most TPAs still can't do [many of the things that employers might want because there are] PPO contracts.” So, is it a rock in a hard place situation? I mean, if the TPA has no other options than using a carrier's PPO (preferred provider organization) network with all its attendant contractual issues, then yeah, that is one definite challenge. Along these lines, let me read a post by Rina Tikia, because I think she sums up this really well. “When independent TPAs … push for transparency, they're blocked under the banner of ‘fiduciary risk.' “Meanwhile, the largest carriers and PBMs, with Cayman shell subsidiaries, DOJ kickback probes, [huge] hedge fund ties, [$10 million-plus] lobbying budgets, and antitrust violations continue unchecked. They are not only allowed to operate but celebrated as mainstream options. “Why the double standard? Political donations? Foundation smokescreens? Nonprofit status as a PR shield?” These are excellent questions. And here's another challenge: brokers. Ramesh Kumar Budhani wrote about this one, just how hard it is sometimes to find—for TPA, an independent TPA, trying to do the right thing—to find brokers who prioritize doing the right thing for employers and helping their clients save money. The summary of all of this: There are TPAs and there are ASOs who aren't even trying. They are going to ride the flywheel, the gravy train, and catch all of the dollars flying off of it for as long as they can manage to cling to it with all 10 of their fingers. Then there are TPAs, mostly indies, trying super hard to do the right thing. But how successful they are is going to depend on how boxed in they are by the PPO networks or the carriers that the brokers or even plan sponsors may insist on. Just how courageous they are and just how smart they are and experienced they are about the market and how it actually operates. So, the show that follows is about all of this, including how we can inspire TPAs, which, in the show that follows, subsumes ASOs kind of into it. But in the show that follows, I hope it's inspiring to create an environment so that the market demands TPAs that do all of the things, and we make inertia not a viable business strategy. Elizabeth Mitchell, my guest today, currently serves as the president and CEO of the Purchaser Business Group on Health. Also mentioned in this episode are Purchaser Business Group on Health; Bryce Platt; Claire Brockbank; Cynthia Fisher; Justin Leader; Kimberly Carleson; Ann Lewandowski; Jeff Evans; Peter Hayes; Luke Prettol; Jason Shafrin; Jeff Marr; Daniel Polsky; Mark Meiselbach; Eric Bricker, MD; Tom Nash; Patrick Moore; Rina Tikia; Ramesh Kumar Budhani; Mark Cuban; Harold Miller; Chris Deacon; Moby Parsons, MD; Benjamin Schwartz, MD, MBA; Mishe Health; Rik Renard; and Cora Opsahl. You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH), advances its strategic focus areas of advanced primary care, functional markets, and purchasing value. She leads PBGH in mobilizing health care purchasers, elevating the role and impact of primary care, and creating functional healthcare markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. At PBGH, Elizabeth leverages her extensive experience in working with healthcare purchasers, providers, policymakers, and payers to improve healthcare quality and cost. She previously served as senior vice president for healthcare and community health transformation at Blue Shield of California, during which time she designed Blue Shield's strategy for transforming practice, payment, and community health. Elizabeth served as the president and CEO of the Network for Regional Healthcare Improvement (NRHI), a network of regional quality improvement and measurement organizations. She also served as CEO of Maine's business coalition on health (the Maine Health Management Coalition), worked within an integrated delivery system (MaineHealth), and was elected to the Maine State Legislature, serving as a State Representative. Elizabeth served as vice chairperson of the U.S. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Committee, board and executive committee member of the National Quality Forum (NQF), member of the National Academy of Medicine's “Vital Signs” Study Committee on core metrics, and a guiding committee member for the Health Care Payment Learning & Action Network. Elizabeth holds a degree in religion from Reed College and studied social policy at the London School of Economics.   08:06 What is the overarching context for health plans in healthcare purchasing? 11:31 Why is it important to reestablish a connection between the people paying for care and people providing care? 13:47 What are the needs of a self-insured employer when managing employee benefits? 19:00 Is it doable for employers to set their own contracts? 21:24 Is transparency presumed? 22:39 Will the new transparency upon us actually expose wasted expense? 24:23 EP408 with Chris Deacon. 25:58 “This is not about individual bad actors. … The systems … that is not aligned.” 27:39 Are there providers who want to work directly with employers? 30:53 Why is it important that incentives need to be aligned? 32:42 EP427 with Rik Renard. 33:51 What's missing from the conversation on changing health plans?   You can learn more at PBGH and by connecting with Elizabeth on LinkedIn.   @lizzymitch2 of @PBGHealth discusses #TPA and #healthplan vs. #jumboemployer inertia on our #healthcarepodcast. #healthcare #podcast #financialhealth #patientoutcomes #primarycare #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Jonathan Baran (Part 2), Jonathan Baran (Part 1), Jonathan Baran (Bonus Episode), Dr Stan Schwartz (Summer Shorts), Preston Alexander, Dr Tom X Lee (Take Two: EP445), Dr Tom X Lee (Bonus Episode), Dr Benjamin Schwartz, Dr John Lee (Take Two: EP438), Kimberly Carleson, Ann Lewandowski (Summer Shorts)