Relentless Health Value

Humana is a payer with its own PBM and a financial incentive to deny care — and it also now owns CenterWell and Conviva, primary care organizations serving roughly 250,000 seniors. In this episode, Stacey Richter presses Vivek Garg, MD, MBA, chief medical officer of Humana's Primary Care Organization, on how that tension actually gets navigated day to day, and what it takes for a vertically integrated payvider to build a model that genuinely serves patients rather than just its own shareholders.

WHAT YOU'LL LEARN

✅ The "dyad model" Dr. Garg uses to align clinicians and administrators: doctors and admins shadow each other so clinicians learn the business of medicine and administrators learn what it's actually like to be a clinician, or a patient, on the receiving end of a policy

✅ Dr. Garg's three pillars for sustainably delivering better healthcare: focus on patient experience, focus on outcomes, and genuinely engage and protect clinical teams as a finite, precious resource

✅ Why longer time horizons matter so much for anything preventative or relationship-based — and why risk adjustment incentives, especially for payviders, tend to work against exactly that kind of long-term thinking

✅ Why Dr. Garg argues it's a mistake to lump all payviders, all Medicare Advantage plans, or all advanced primary care organizations together as uniformly good or bad — the self-interest is always there, but its impact on patients has to be judged case by case

✅ How much an organization's investment in clinical leadership shapes whether individual clinicians can actually pursue the reasons they went into healthcare in the first place

WHY THIS MATTERS

Stacey is upfront about her own skepticism of vertically consolidated payers — and the point of this conversation isn't to resolve that tension but to sit inside it. Self-interested, shareholder-centric goals aren't automatically disqualifying, but they have to be weighed against real impact on patients, clinicians, and community, case by case, organization by organization. Utopia isn't on the table; the real question is whether a given payvider's version of "doing well by doing good" nets out positive for the patients actually in the room.

MENTIONED IN THIS EPISODE

EP312 with Doug Eby, MD, MPH, CPE: Apple Podcasts | Spotify | Other Apps

AEE12 with Steve Blumberg: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

07:27 What does comprehensive primary care look like, and what can we expect from it?

07:39 Is the comprehensive primary care model the single biggest tool to help improve health?

10:41 How does a competitive ecosystem affect a comprehensive primary care model?

15:44 What is the impact of physicians and clinicians on the delivery of comprehensive care?

20:22 "What we need to do with the technology is actually support and enable the team."

21:42 Why it's important to create "space" in your comprehensive care model.

24:56 What three areas does every organization need to pay attention to?

31:03 Why the opportunity for alignment is greater than the potential for conflict.

32:48 Why long-term orientation is a key to success, even in an ecosystem that's more short-sighted.

Why don't more self-insured employers' benefits departments do more to fix the ways they're getting fleeced on healthcare spend? In this episode, Stacey Richter talks with Lauren Vela, an independent consultant who previously led healthcare transformation work at Walmart and market strategy at the Purchaser Business Group on Health, about the five structural reasons benefits teams stay stuck in inertia — even when everyone agrees the status quo is costing employers and employees real money.

WHAT YOU'LL LEARN

✅ The five reasons Lauren Vela identifies for inertia in benefits departments: transforming healthcare isn't actually in the job description, heavy reliance on consultants who often have a vested interest in the status quo, the "nobody gets fired for hiring the same vendor" dynamic, the lack of an obvious silver-bullet solution, and plain status quo bias

✅ Why some traditional employee benefit consultants and brokers can skim commissions of up to 30% of pharmacy or healthcare spend — and why that gives them little incentive to recommend disruption

✅ Why benefits teams often lack the bandwidth, staffing, or C-suite air cover to manage what amounts to running a small insurance company in-house, on top of their regular jobs

✅ The two starting solves Lauren Vela and Stacey land on: getting real C-suite involvement and resourcing for benefits teams, and vetting consultants specifically for ones not taking undisclosed indirect compensation

✅ Why "can we afford to spend more on our benefits department" is the wrong question — the real question is whether employers can afford not to, given how much is currently being siphoned out of healthcare spend

WHY THIS MATTERS

Employers are wasting up to 30% or more of their healthcare benefits spend, according to Lauren Vela — dollars that could have gone toward employee raises or better health outcomes instead of getting quietly skimmed off the top. Benefits teams aren't necessarily failing because they don't care; they're often under-resourced, under-supported by their own C-suites, and stuck working with consultants who profit from the status quo. Fixing that requires structural change, not just good intentions from the people already doing the job.

MENTIONED IN THIS EPISODE

EP358 with Wayne Jenkins, MD: Apple Podcasts | Spotify | Other Apps

EP397 with Paul Holmes: Apple Podcasts | Spotify | Other Apps

EP244 with Lee Lewis: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

07:16 What does inertia actually mean in the healthcare benefit space?

08:02 "Fixing healthcare is not really the benefit manager's job."

08:22 How could a benefit manager's job actually do the opposite of making healthcare better?

11:56 "Americans are in pain."

13:31 Why do benefits managers partner with consultants, and why is that bad?

14:17 "Benefit departments are cost centers; they're not revenue centers."

15:30 "Every single company is in the healthcare business."

18:12 Why relationships with consultants can make it very difficult for benefits departments to change.

22:46 Is the juice worth the squeeze?

23:12 "There's not one silver bullet that fixes healthcare."

27:42 What is status quo bias?

28:56 Why employers may not be able to stay with their legacy vendors and also change for the better.

North Carolina's Hospital Price Transparency Fight, With Dale Folwell (Encore EP249)

Why North Carolina's Legislature Was Moving the Wrong Way on Healthcare Costs. Encore Episode 249.

While states like Texas, Indiana, and Wisconsin have moved to rein in hospital and insurer consolidation, North Carolina's Republican-led legislature was, at the time of this encore, considering two bills that push the opposite direction. In this encore episode, Stacey Richter revisits her 2019 conversation with Dale Folwell, CPA, North Carolina State Treasurer, about his fight to bring transparent, network-based pricing to the State Employees Health Plan (SEHP) — and adds new context on two 2023 bills that could undercut that work.

WHAT YOU'LL LEARN

✅ Why a bill letting Blue Cross Blue Shield of North Carolina create a for-profit holding company for policyholder payments has historically preceded premium increases in other states that allowed similar conversions

✅ Why a second bill would let UNC Health Care expand with less regulatory oversight, ostensibly to prop up struggling rural hospitals — despite evidence that unchecked consolidation tends to raise costs without improving outcomes

✅ What the Clear Pricing Project is and why North Carolina's State Employees Health Plan proposed it

✅ Why some of North Carolina's largest hospital systems fought back against transparent, network-based pricing

✅ Why Treasurer Folwell frames this fight over healthcare costs as core to the state's fiscal and economic health, not just a benefits-department issue

WHY THIS MATTERS

North Carolina's SEHP fight over transparent pricing was a genuine attempt to use a state's purchasing power to bend hospital costs — and the pushback it drew from the state's largest hospital systems shows exactly what's at stake. The two bills revisited in this encore suggest the state's legislature may be moving toward less transparency and more consolidation just as other states move the opposite way, which is exactly the kind of divergence Stacey flags as worth everyone's attention, not just North Carolina's.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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This is a companion conversation to EP402 with Amy Scanlan, MD: Stacey Richter asks Eric Gallagher, CEO of Ochsner Health Network, the same core question she put to Dr. Scanlan — what does it actually take to help physician practices align into an integrated model? Ochsner Health Network is a much more mature clinically integrated network, operating in a Louisiana market with an older population and heavy Medicare Advantage penetration — a very different environment from Dr. Scanlan's earlier-stage Colorado network, which makes it a useful test of which lessons about physician integration hold up across very different local markets.

WHAT YOU'LL LEARN

✅ Why Eric Gallagher considers it essential that physicians and care teams are part of the transformation process from the start — both on the clinical side and the financial side, not just informed after decisions are already made

✅ Why educating physicians on the actual business and financial "why" behind organizational changes matters — insulating doctors from that reality, Gallagher argues, doesn't protect them, it just leaves them confused and resentful

✅ How practice transformation requires process transformation: getting paid to coordinate care means thinking about staff roles, community investment (like Ochsner starting its own schools), and social determinants of health very differently than a pure fee-for-service model ever required

✅ Why culture change — not technology or contracts — is the hardest and most underestimated part of clinical integration, and why inertia is the common enemy across every network regardless of market

✅ Why local market conditions (patient demographics, Medicare Advantage penetration, how far along a network already is) shape which tactics work, even when the underlying strategic principles hold constant

WHY THIS MATTERS

Comparing Ochsner's mature network in Louisiana to Dr. Scanlan's earlier-stage network in Colorado reveals what does and doesn't transfer across markets: the tactical playbook has to be local, but bringing physicians in as genuine partners, explaining the financial "why," and treating culture change as real work rather than an afterthought hold up everywhere. As Stacey notes, healthcare has a bad habit of assuming that what works in one market or one practice will simply scale nationwide — and that assumption is usually where transformation efforts go to die.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

08:14 What does everyone need to be on the same page about when it comes to clinical integration?

13:42 "For physicians, we really have to overcome this threat to physician autonomy."

16:52 "Health inequity is really just societal inequity."

19:24 What is the principal agent problem?

20:00 "There are things health systems can do that are probably outside of their traditional field of responsibility."

20:09 Why did Ochsner Health Network start a couple of schools?

20:42 What can empower a care team in a value-based care model?

21:53 Why is it important to transform into a team-based model?

23:24 "In the DNA of our organization, resiliency runs strong."

26:01 Why is building an effective care model easier than building trust with patients?

26:14 What is Eric's advice to physicians trying to integrate right now?

28:50 How do you get everyone on the same side of aligning for integration?

Nonprofit hospital boards hold enormous power over how these institutions operate — yet almost half of board members come from a finance background, while nearly a third of hospital boards don't include a single physician. In this episode, Stacey Richter talks with Suhas Gondi, MD, MBA, a resident physician at Brigham and Women's Hospital who, along with coauthor Sanjay Kishore, MD, published research and a STAT News piece examining exactly who sits on these boards and what that composition means for the priorities big, consolidated, and often tax-exempt hospital systems actually pursue.

WHAT YOU'LL LEARN

✅ Just how skewed hospital board composition really is: nearly half of members have a finance background, almost none are nurses, and about a third of boards have zero physician members at all

✅ Why Dr. Gondi and his coauthor argue that boards dominated by finance professionals and corporate leaders are more likely to prioritize revenue and expenses over community and staff needs, even at nonprofit, tax-exempt hospitals

✅ Three concrete models for diversifying hospital board composition: mandating patient representation the way Federally Qualified Health Centers require 50% patient board members, requiring the kind of professional and demographic diversity NASDAQ mandates for public company boards, and reserving seats for workers elected by frontline staff, per Senator Elizabeth Warren's Accountable Capitalism proposal

✅ Why transparency about who sits on these boards and what decisions they're making matters just as much as who's in the room — and how IRS tax-exempt status requirements could be used as leverage

✅ How the same playbook — cutting costs while raising prices — that shows up in private equity deals also shows up at big nonprofit hospital systems, even ones that later blame investment losses on hard times

WHY THIS MATTERS

As Dr. Gondi and Sanjay Kishore write, "If hospital executives are largely held accountable by finance professionals and corporate leaders, instead of by clinicians and patients, might they focus more on revenue and expenses than the needs of their communities or staff?" Hospitals are tax-exempt because they owe something back to the communities that subsidize them — and a board that doesn't reflect clinicians, patients, or that community has little structural reason to prioritize their interests over its own.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

05:26 What's a hospital board, and how much power do they have over goings-on?

06:51 How big is a hospital board typically?

07:45 How powerful is a hospital board actually?

09:12 What percentage of these board members have roles within the finance industry?

10:04 What percentage of these hospital board members are health professionals?

10:47 How do these hospital boards work?

12:44 Have hospital boards always been made up of financial board members, or is this a recent thing?

18:12 "The private equity model…fundamentally changes the incentives of the organization."

23:21 Are hospital boards a potential place to create change within the healthcare industry?

25:16 "It's about who has power."

30:55 What's the hope with diversifying hospital boards?

Health systems increasingly get paid through value-based or capitated contracts — but the individual physicians actually seeing patients inside those systems are still, more often than not, paid the old-fashioned way: fee-for-service RVUs with a thin layer of quality bonuses on top. In this episode, Stacey Richter talks with Rachel Reid, MD, MS, a physician policy researcher at RAND Corporation and primary care physician at Brigham and Women's Hospital, about a study she co-authored looking at exactly how U.S. health systems compensate and incentivize their physicians — and the five reasons that misalignment persists even when everyone agrees it's a problem.

WHAT YOU'LL LEARN

✅ Why most physicians — including PCPs — are still paid primarily on RVU-based productivity, even when the health system employing them is being paid through value-based or capitated contracts

✅ The five reasons Dr. Reid identifies for why physician compensation models rarely change to match how the organization itself gets paid: insufficient payment size, a fee-for-service "chassis" already baked into most value arrangements, the difficulty and risk of overhauling comp models, plain inertia, and lack of consensus on what to actually incent

✅ Why misaligned compensation is a real driver of physician moral injury — wanting to do right by a patient but not getting paid, or getting in trouble, for doing so

✅ How this plays out for self-insured employers specifically: a plan can pay a health system a value-based or capitated rate for a "medical home," while the PCPs actually seeing members are paid fee-for-service underneath that arrangement, with the difference pocketed upstream

✅ What Dr. Reid recommends plan sponsors actually do about it: write physician compensation expectations directly into the contract, rather than assuming a value-based payment to the organization trickles down to the doctor

WHY THIS MATTERS

"There's no current gold standard for how to pay doctors," Dr. Reid says — which means the industry is left guessing at both halves of the equation: what counts as high-value care, and how to actually pay for it. Until physician compensation is explicitly tied to the same goals a health system's own contract is being paid to achieve, plan sponsors buying "value-based care" or a "medical home" risk paying for an outcome the doctor on the other end has no financial reason to deliver.

MENTIONED IN THIS EPISODE

Study: "Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems" (JAMA Health Forum)

EP295 with Rebecca Etz, PhD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

08:11 Why Dr. Reid decided to do the study in the first place.

09:49 What are the main foundations of what doctors are paid on?

10:31 Why is value-based compensation still just the "icing" on the cake?

13:08 What is the biggest value add for doctors, and does it vary between specialties?

14:32 Why wouldn't a physician organization change their comp models?

19:55 Are we at a moment of evolution?

20:20 "Tying dollars to measured quality gaps doesn't necessarily produce results."

22:04 "I don't think there's a current gold standard for how to pay doctors."

25:37 Job one: What are we trying to incent?

31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?

Standing up a clinically integrated network (CIN) is one thing on a slide deck and another thing entirely in the messy middle of an actual physician practice's day-to-day operations. In this episode, Stacey Richter talks with Amy Scanlan, MD, chief medical officer of the new CIN joint venture between UCHealth and Intermountain Health in Colorado's Front Range — a physician-led network of more than 700 primary care providers. Dr. Scanlan digs into what it actually takes to help practices at very different points in their value-based care journey navigate the transition without losing physicians' trust or overwhelming their teams.

WHAT YOU'LL LEARN

✅ Why giving practices the tools they actually need — not the tools leadership assumes they need — requires genuinely listening to physicians first, not just rolling out a standard playbook

✅ What Dr. Scanlan means by the "in-between spaces": the time between appointments where data, technology, and a behind-the-scenes team determine whether patients actually get the care they need

✅ Why medical culture has to shift toward functional, collaborative teams — and why team-based care done badly, as Dr. Scanlan puts it, is "really just a series of handoffs," which is exactly when patients are most at risk

✅ Why value-based, integrated care requires thinking as much about the patients who don't show up for appointments as the ones who do — a much bigger mindset shift than it sounds

✅ Why physician burnout, in Dr. Scanlan's view, is actually a hopeful sign: proof that most physicians still care deeply about doing right by patients, even inside a system working against them

WHY THIS MATTERS

"Physicians are the backbone of this system," Dr. Scanlan says — and Stacey frames the stakes even more bluntly beforehand: healthcare businesses need infrastructure, data, and teams to succeed under value-based payment, and that costs real money, which raises the uncomfortable question of how much profit is too much before "doing well" tips into "financial toxicity." Getting clinical integration right isn't just an operational challenge; it's about whether physicians can lead this transformation on terms that still put patients first.

MENTIONED IN THIS EPISODE

Article: "Doctors Aren't Burned Out From Overwork. We're Demoralized by Our Health System." by Eric Reinhart, MD, PhD (New York Times)

EP393 with David Muhlestein, PhD, JD: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

06:33 How is Dr. Scanlan thinking about the transformation process and the shift to value?

09:14 "It is really trying to think about, how do we help practices get there?"

11:46 "The hard part is the in-between spaces."

14:10 "Team-based care done badly is really just a series of handoffs."

15:50 "We have to get to that point where the culture of collaboration is more pervasive."

19:57 "How do we as healthcare providers step in and solve this problem?"

20:04 Why do providers have a responsibility to step in and try to fix the healthcare system?

21:50 Why do physicians need to be accountable for the cost of care as well as outcomes?

23:37 Why does physician burnout give Dr. Scanlan hope?

24:25 What is the solution to changing fee-for-service incentives?

25:42 What are some of the challenges facing changing incentives?

27:14 Why is data so important?

30:11 "It's important to understand that we are in the middle of this change."

31:16 Dr. Scanlan's advice for those trying to stand up a CIN.

The Inflation Reduction Act gives Medicare, for the first time, the authority to negotiate prices directly with drug manufacturers — but whether those negotiated prices actually track a drug's value is a question host Stacey Richter says she doesn't hear discussed often enough. In this episode, she talks with Peter J. Neumann, ScD, director of the Center for the Evaluation of Value and Risk in Health (CEVR) at Tufts Medical Center and coauthor, with Joshua Cohen and Daniel Ollendorf, of The Right Price: A Value-Based Prescription for Drug Costs. Dr. Neumann walks through what the IRA's negotiation provisions actually do, and roughly eight second-order effects — from launch-price inflation to shifting R&D incentives — that could determine whether the law ends up rewarding genuinely valuable drugs or just squeezing list prices.

WHAT YOU'LL LEARN

✅ How CMS's negotiation authority actually phases in: the top 10 Part D drugs in 2026, 15 Part D drugs in 2027, and 15 Part B and D drugs in 2028 — with small molecules eligible after 9 years on the market and biologics after 13

✅ Why that 9-year/13-year gap creates a strong incentive for pharma to favor biologics over small molecules, potentially at the expense of needed drug categories like new antibiotics

✅ Why value-based pricing and cost containment are not the same goal, and why Dr. Neumann says it's unclear whether the IRA is really designed to achieve the former or is mostly about the latter

✅ How the law's incentive structure could push manufacturers to raise launch prices before a drug becomes subject to inflation caps and eventual negotiation

✅ Why a high price doesn't necessarily mean poor value — and why Dr. Neumann argues some million-dollar drugs are reasonably priced given the health benefits they deliver

✅ Why siloed pharmacy and medical budgets can cause high-value drugs to be underused, even when they generate real downstream medical savings

WHY THIS MATTERS

The point Dr. Neumann keeps returning to is that pricing on value requires information the current system rarely provides — and the law itself bans Medicare from using quality-adjusted life years, one of the few standardized tools for comparing value across wildly different drug categories. Whether the IRA ends up rewarding therapeutic advances or simply squeezing list prices will depend entirely on how CMS operationalizes it over the next several years — and, as Stacey notes, that's a story still being written.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

09:33 Is it imperative that drugs whose patents are expiring have their prices negotiated?

10:50 "We need innovation; we want to encourage innovation."

11:01 Does this new law strike a balance between innovation and price regulation?

11:21 How are we assessing cost effectiveness and innovation in the drug space?

12:29 What's the problem with the current drug markets?

13:14 Why can't you rely on the drug market for the cost effectiveness of a drug?

14:13 Why very expensive drugs do not equate to poor value.

15:06 What are the likely outcomes of the IRA?

18:33 How does pharmacy budget factor into high-value drugs?

19:26 "Value-based pricing doesn't mean necessarily lower spending overall."

22:59 What are the types of drugs that will be excluded from the IRA?

23:22 Who will the law create problems for?

24:44 What have pharmacy benefit managers (PBMs) been doing to move forward with the new law?

26:04 What are plan sponsors doing right now?

28:32 What are the most important value metrics according to Dr. Neumann?

This is Part 2 of a two-part exploration of what host Stacey Richter calls her manifesto — not a mission statement so much as the practical framework she uses to decide who to work with and what to say yes to in an industry where nearly every stakeholder, patients included, has some measure of self-interest at play. Picking up from Part 1 (EP399), Stacey works through the messy calculus behind decisions large and small — from vetting a new consulting client to deciding whether to help a Medicare Advantage plan get patients to their annual wellness visit, a program tangled up in risk adjustment and star ratings. What emerges is a three-part personal manifesto for operating with integrity inside a financialized healthcare system where almost no one is unconflicted.

WHAT YOU'LL LEARN

✅ Stacey's three-part manifesto for deciding what to work on: the thing must be a net positive for patients, the timeframe is short- to medium-term, and the assumption is that transforming healthcare takes a village

✅ Why the financialization of healthcare means nearly every stakeholder — hospitals, payers, drug companies, even physicians — is operating with some degree of self-interest baked into their incentives

✅ The two-part calculus Stacey runs before taking on a client or backing an initiative: how much good does it actually do for patients, and where's the money coming from and who wins

✅ Why incremental change and disruptive change aren't in competition — and how the two can actually reinforce each other rather than requiring an either/or choice

✅ A real-world thought experiment — helping a Medicare Advantage plan get members to an annual wellness visit — that shows how risk adjustment and star ratings complicate even a seemingly obvious "yes"

✅ Why Stacey believes no single person or organization can fix healthcare alone, and how thinking of the industry as a village keeps her from freezing up over unintended consequences elsewhere in the system

WHY THIS MATTERS

Every dollar someone takes in profit under the banner of improving health, Stacey points out, is a dollar someone else paid — which is why figuring out who's genuinely aligned with patients versus who's just doing well by doing good matters. Her manifesto isn't a call for purity or a demand that everyone she works with be unconflicted; it's a practical filter for operating with integrity inside an industry where almost no one is. As she puts it, "It's basically up to us as individuals to do the right thing."

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction.

03:16 "It's a zero-sum game."

03:26 Is the amount of profit fair?

03:37 What is an inescapable fact of the healthcare industry?

03:54 What does the financialization of healthcare mean?

04:19 Why does the self-interest in healthcare matter?

06:18 "It's basically up to us as individuals to do the right thing."

10:03 What is the first part of Stacey's manifesto?

10:18 How does Stacey calculate the net positive of an impact?

10:41 What are two major upsides/downsides that Stacey contemplates?

13:31 Why are incremental change and disruptive change not mutually exclusive?

17:40 "I always try to keep in mind that it will take a village."

19:19 Why finger pointing is killing innovation in healthcare.

Who Is Auditing These Healthcare Bills? Also, That Cigna Lawsuit, With Dawn Cornelis, Cofounder and Director of Transparency at ClaimInformatics (Encore! EP285)

In this Encore, prompted by a Cigna class-action lawsuit alleging fraudulent lab billing, Stacey Richter revisits her conversation with Dawn Cornelis, cofounder of ClaimInformatics, about the roughly 30% of healthcare claims spending that's some combination of fraud, waste, and abuse.

WHAT YOU'LL LEARN

✅ The details of the Cigna lawsuit alleging a pseudonym lab entity was used to inflate a member's out-of-pocket costs

✅ The three main categories of claims problems: paid incorrectly, missed opportunities to help members, and claims that shouldn't have been submitted at all

✅ Why 5% to 10% of claims simply aren't paid correctly, according to Dawn's audit work

✅ Why some audit and recovery firms also do revenue optimization work for providers — the same providers whose claims they're supposed to be auditing

✅ Why plan sponsors need to ask who is auditing their claims data, and by whom

WHY THIS MATTERS

The Cigna lawsuit is a headline-grabbing example of a much bigger, quieter problem: roughly 30% of healthcare spending is fraud, waste, or abuse, and plan sponsors often don't know whether their claims are being audited by a firm with a conflicting revenue-optimization relationship with the very providers submitting those claims. Asking who's auditing the bills — and whether that auditor has skin in the other side of the game — is a basic fiduciary question too many plan sponsors haven't asked.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

06:57 The story in the data.

07:33 Who's submitting these claims?

08:04 The three problems with the data.

10:54 The varying factor between carrier systems to stop fraud, waste, and abuse.

11:32 Why carriers don't push for better systems to stop inappropriate dollars.

13:28 The difference between fraud, waste, and abuse.

14:46 "When it becomes the norm, that's what's very bothering."

15:10 The barriers or hurdles in the marketplace.

17:38 What we don't know about but could do better at when looking at the data.

19:10 "It's not so much the health system and what they are charging. It's about…what the contracted rate is agreed to."

20:04 "Data's fixed for itself."

22:49 Identifying and eliminating fraud.

22:54 The lack of enforcement behind preventing illegal billing.

26:01 How providers ensure they aren't inadvertently harming employers and patients through billing.