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Reference-based pricing has come a long way from its early days. While eye-popping savings got employers interested, RBP created enough disruption to make you wonder if the savings were worth the headaches. Then the model grew up. Jeff Kweder, president of Shepherd Insurance, and Shepherd Advisor Steven D. Goodin join Danielle Young on this episode of ClaimTalk to trace RBP’s evolution over the years. They provide firsthand insight into how it transformed from a desperate last resort into a sustainable strategy that still has undeniable savings — but that also gives employers greater control, stronger member support and proactive provider outreach.

Roughly one in five medical claims is denied, yet only a fraction of patients ever appeal. Denials aren't just an administrative headache. They're becoming a barrier to necessary care in a system that makes it confusing for people to challenge the decision. On this episode of ClaimTalk, Claimable, Inc. Co-Founder and Chief AI Officer Zach Veigulis and Head of Engineering Ben Goerdt join host Danielle Young to explain how Claimable uses AI to give patients a fighting chance in a process that oftentimes doesn't go their way. They show how stronger appeals — backed by clinical evidence, legal protections and patient stories — can challenge denials and expose just how often a finding of “not medically necessary” doesn’t hold up under scrutiny. In a world where AI is already being used to deny claims faster, this episode explores in detail how Claimable harnesses the same technology to help patients navigate an increasigly complex system.

Medical claim denials are necessary to protect plan dollars from abuse, but for patients they can mean delayed treatment, financial hardship and life-altering uncertainty. On Episode 26 of ClaimTalk, we welcome Zach Veigulis, co-founder and Chief AI Officer of Claimable, an AI-powered medical claims appeal platform. Zach visits with ClaimDOC President Bruce Hansen, SVP and Chief Legal Officer Amy Pelligren, and host Danielle Young about why most denied claims go unchallenged, how the appeals process stacks the deck against patients and what happens when people are left to fight the system alone. The discussion examines common denial practices and highlights the growing need for transparency, accountability and member advocacy in health insurance.

Can the problems with health insurance actually be fixed? In Part 2 of this ClaimTalk conversation, CEO Ben Krambeck, Vice President of Provider Relations Brad Hansen and Vice President of Audit Services Cynthia Swanson continue unpacking how we got here — and what it will take to change course. Building on Part 1, they explore with host Danielle Young how well-intentioned innovation, shifting demographics and policy decisions have combined to create a system that’s increasingly expensive, complex and unsustainable for employer health plans. More importantly, they move beyond diagnosis to discuss what a path forward could look like. They address the unexpected negative impact of consumer transparency rules, the role of legislation and skyrocketing pharmacy costs.

Purchasing healthcare didn’t become this complicated overnight. So how did we get here? Our industry experts — CEO Ben Krambeck, Vice President of Provider Relations Brad Hansen and Vice President of Audit Services Cynthia Swanson — join Danielle Young on a new ClaimTalk to trace the policy decisions, reimbursement shifts and billing changes that helped create today’s health insurance mess. From the Affordable Care Act to questionable billing practices to the coding complexity still driving costs and confusion, their conversation breaks down how the system changed — and how understanding that history can lead to better decisions for employer health plans.

Convincing consultants to bring reference‑based pricing to clients isn’t easy. Paul Saunders, executive vice president at Saunders & Company, knows firsthand as someone who once was "totally opposed" to RBP. That changed when he saw how a dual‑option approach could work: pairing a traditional health plan with a lower‑cost RBP option and letting members choose what fits them best. In this month's episode of ClaimTalk, Saunders joins ClaimDOC’s Omar Arif and Stephanie Mohr to explore how dual‑option plans help brokers address rising renewal costs without forcing employers into an all‑or‑nothing decision. They explore why offering choice may be the most practical path to affordability, client confidence and long‑term satisfaction.

Who's a good third-party administrator? There are many to choose from, but far fewer that consistently deliver when it matters. And the difference between a good TPA and a mediocre one often determines whether a health plan works exceptionally well or frustrates everyone it touches. Our last two episodes of ClaimTalk weren't kind to TPAs. While much of that criticism was earned, the reality is that TPAs operate in a landscape that is complex, constrained and often misunderstood. On this episode, Luke Schafer of BRMS joins Danielle Young, Shay Butler and Dallas Lovell to discuss why the strongest TPAs are the ones that stay in their lanes and are laser-focused on their primary responsibility — paying claims.

Selecting the right vendors for a reference-based pricing health plan isn’t an exact science. At the end of the day, it often comes down to experience, discernment, and the ability to read the signals vendors give off long before the contract is signed. In this episode of ClaimTalk, Emma Fox, CHVA joins Danielle Young, Bruce Hansen and Stephanie Mohr to continue their unapologetically candid examination of vendor dynamics to offer pointed insights on evaluating partners that can make or break a self-funded strategy. They break down what truly constitutes “good” and “bad” vendor vibes, define what real competency actually looks like, and outline how to identify red flags before they turn into costly mistakes. If you’re serious about elevating your self-funded health plan performance, this conversation cuts through the noise and shows you what to look for, because not every vendor deserves a seat at your table.

Building a successful self-funded health plan demands skilled and efficient vendor partners that have the expertise to deliver on their promises. Identifying the best vendors can be challenging, and settling for substandard partners can lead to less-than-desirable outcomes. But how do you find the best partners? On this episode of ClaimTalk, Emma Fox, CHVA gets brutally honest during the first half of a two-part conversation with Danielle Young, Bruce Hansen and Stephanie Mohr on the struggles that can arise with vendors. While a good portion of the discussion centers on the issues they've experienced with third-party administrators, they also discuss why it can be difficult to find the right partners, the strategies they use to identify dependable vendors, and why some of the most unreliable vendors continue to survive in the industry.

In 2022, Featherlite Trailers partnered with ClaimDOC to begin implementing a new reference-based pricing health plan for its employees. It's no secret that moving to an RBP plan can come with friction but, with Shannon Westin, SHRM-SCP leading its human resources department, Featherlite didn't just endure the change, they owned it.  Westin joins Danielle Young and Amy Hansen on ClaimTalk this month to share how taking the time to truly understand the plan and being proactive in resolving potential issues caused watercooler talk to shift from uncertainty to appreciation.

If your organization sponsors a self-funded health plan and cybersecurity isn’t part of your vendor evaluation criteria, it’s time to reassess. Protecting your own infrastructure is essential, but it’s not enough. Every vendor with access to your data must meet rigorous cybersecurity standards. Otherwise, you're not just accepting risk, you're creating it. In this episode of ClaimTalk, Andrew Smith and Jeremy Schuller share with Danielle Young some of the threat tactics that cybercriminals are using today and discuss best practices in evaluating vendors to ensure your data will be secure.

Paying cash for healthcare services is not a new concept, but it's also an option that is not widely used. The reason for that is because many providers prefer to accept reimbursement from insurance. But cash pay does have its advantages. On this episode of ClaimTalk, Danielle Young visits with Amy Pellegrin and Leah DeBartolo about the pros and cons of cash pay, how health plans can create service around cash pay, and what stands in the way of cash becoming a more popular payment option for healthcare.

For nontraditional health plans to work — whether they use reference-based pricing or another strategy — they often require customized solutions. As health plans evolve, vendors can't ignore new methods to give plan members what they need. In this episode of ClaimTalk, Amy Pellegrin and Stephanie Mohr visit with Sharla Mallett, a member of our direct primary care team. They discuss how the DPC team works to give members a more personalized health plan experience and why making adjustments to health plans is crucial to providing a positive member experience.

Whether you're using a reference-based pricing strategy or some other alternative, there are many challenges in creating an effective direct contract. Much of the time, they boil down to the complexities of healthcare pricing in one way or another. Whether it's compliance with regulations, plan design or services billed by a third party, creating an effective direct contract requires a partner with the expertise to help you maneuver through all elements of the agreement. This month, Jay Kempton, Shane Cerone and Brad Hansen return to ClaimTalk for the second half of an in-depth discussion on direct contracts and how to navigate inconsistencies in healthcare pricing.

Healthcare access can be the biggest hurdle to successfully implementing a reference-based pricing plan. Sometimes it requires creating an agreement called a direct contract between a health plan and a provider to ensure access to that provider. Direct contracts are an effective tool for RBP health plans, but they can be more complicated than they sound.  On this month's ClaimTalk, experts Jay Kempton, Shane Cerone and Brad Hansen discuss the complexities of direct contracts and their impact on the rising cost of healthcare.