Your Fiduciary Risk Is Real & Growing
ClaimInformatics is the gold standard in fiduciary protection for self-funded and captive health plans and TPAs
$74B
Personal Liability
Every year, self-funded and captive health plan fiduciaries face $74 billion in personal liability - a silent threat lurking in unchecked claims, hidden overpayments, and complex billings.
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Without rigorous oversight, plan assets and even your personal finances are exposed to costly errors, fraud, and regulatory penalties.
Fiduciary Compliance Through Payment Integrity
Protecting You from Fiduciary Risk
FOCUS™ - Fiduciary Oversight, Compliance & Utilization Safeguard
ClaimInformatics delivers unmatched fiduciary oversight through our proprietary FOCUS framework — ensuring compliance, transparency, and financial integrity.
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ClaimIntelligence™ Edit Library: Built on CMS NCCI, OCE, and ICD-10-CM rules, delivers conflict-free oversight before and after payment — protecting fiduciary trust across every claim, including Episode of Care logic to detect complex billing patterns and systemic errors
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Unbiased, conflict-free verification ensuring no vendor influence
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Recovery share - clients receive 50% of recovered funds
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Ongoing Monitoring for early detection - stop errors before they escalate
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Complete Lifecycle Management: Pre and Post-Pay solutions ensure full coverage
At ClaimInformatics, we equip you with complete transparency and forensic-level accuracy to identify improper payments, protect plan assets, and fulfill your fiduciary duties under ERISA and the Consolidated Appropriations Act (CAA).
Don’t let hidden risks compromise your plan or your personal liability.
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Detect
Error & Risk Detection
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One to three-year historical claims analysis evaluating 100% of claims
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Flags pricing errors, abuse, and systemic payment failures
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Valuable diagnostic tool for uncovering past inefficiencies and assessing fiduciary oversight risks
​Protect
Proactive Compliance and Plan Integrity
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Ensures compliance with ERISA,
CAA, as well as the plan documents -
Identifies financial leakage and overpayment at the source
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Creates a defensible audit trail and reinforces prudent plan oversight
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Proactive, fiduciary-focused solution monitors claims monthly, ensuring compliance and early issue detection
Recover
Intelligent Overpayment Reclamation
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Recovers identified overpayments
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Fulfills fiduciary obligations by
restoring plan assets -
Included with PAIR and OM, the client receives 50% of the recovered funds
ClaimIntelligence™
Setting The Industry Standard for Payment Integrity & Fiduciary Compliance
Our solutions prevent errors before payment, detect risk after, or on an ongoing basis, ClaimInformatics protects fiduciary trust throughout.
ClaimInformatic's SOC 2-certified, HIPAA-compliant service is the only comprehensive solution for self-funded and captive plan fiduciaries and TPAs, offering fiduciary protection by turning claims data into actionable insights. Ensures transparency, reduces liability, and maintains compliance while saving costs and providing measurable value.
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​Our proprietary edit suite focuses on identifying high-impact claim errors that drive immediate financial and compliance benefits. ClaimInformatics accomplishes this by applying industry standard coding guidelines surrounding, but not limited to CPT®, HCPCS, and ICD-10-CM, including:
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Industry Guidance
Industry Guidance: Edits based on widely accepted best practices, payer consortium recommendations, or professional society guidelines (outside of CMS). These include sources such as AMA, specialty societies, or industry-standard coding manuals that reinforce proper billing and coding integrity. 
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Fraud, Waste, and Abuse
Edits flag suspicious or non-compliant billing patterns. They focus on overutilization, duplicate billing, upcoding, unbundling, or services that are not medically necessary. These rules support the detection of potential fraud schemes or improper billing practices. 
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Drugs and Biologicals
Edits related to billing for medications, injectables, infusions, and biologics. These checks ensure correct NDC/HCPCS coding, units of service, dosage, and waste billing (JW modifier), as well as that the drugs are FDA-approved, covered, and medically necessary for the reported diagnosis. 
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IPPS (Inpatient Prospective Payment System
A Medicare payment system that reimburses hospitals for inpatient stays based on assigned DRGs. IPPS edits validate coding for inpatient admissions, sequencing of principal and secondary diagnoses, procedure codes, and discharge status to ensure accurate DRG assignment and payment. 
✅ Outcome: Immediate savings, improved coding compliance, and reduction of audit exposure. ​​​​
Broad Category and Specialty Coverage
Edit Categories
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APC (Ambulatory Payment Classifications)
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ASC (Ambulatory Surgery Center)
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CMS Guidelines
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Code Deletions/Revisions
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DRG (Daily Rate / Diagnosis-Related Group)
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Drugs and Biologicals
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Episode of Care
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FWA (Fraud, Waste, and Abuse)
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Industry Guidance
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IPPS (Inpatient Prospective Payment System)
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PDPM (Nursing Home Related)
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Sequencing (Order of Codes Not Correct)
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Summary Plan Descriptions (SPDs)​
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Edit Specialities
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Primary Care
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Specialty Care
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Surgical Specialties
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Behavioral & Mental Health
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Emergency & Critical Care
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Rehabilitation & Allied Health
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Diagnostic & Ancillary Services
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Preventive & Public Health
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Coding-Related
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✅ Outcome: Transparent, data-backed evidence of performance that supports both financial reporting and compliance documentation.
Learn More About Claiminformatics Offerings
The Growing Fiduciary Risk You Can’t Ignore
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Unseen Overpayments Drain Your Plan: Auto-adjudication prioritizes speed over accuracy, while TPAs and networks profit from undetected errors.
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Complex Billing Masks Fraud and Abuse: Upcoding, hidden fees, and price gouging silently inflate costs, sometimes by tens of thousands of dollars per provider annually.
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Personal Liability Is Real: Under ERISA, fiduciaries can be held personally liable for losses resulting from breaches of duty, which may put their homes, retirement savings, and careers at risk.
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Regulatory Scrutiny Is Intensifying: The Department of Labor is ramping up enforcement, and recent lawsuits set precedents that increase fiduciary exposure.
Why ClaimInformatics?
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True Independence: No revenue from TPAs, networks, PBMs, or providers - your fiduciary interests come first
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Enterprise-Grade Security: SOC 2-certified and HIPAA-compliant platform protects your sensitive data
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Unmatched ClaimsIntelligence: Proprietary AI-derived algorithms coupled with our Episode of Care™ logic uncover what others miss
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Fiduciary Duty Alignment: Supports duties of loyalty, prudence, monitoring, fee reasonableness, and plan document adherence
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Transparent Recovery Model: You share 50% of recoveries with full reconciliation and provider notifications
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Strategic Advantage for Brokers: Differentiate your services by offering clients measurable fiduciary protection and cost control
We Stand By Our Clients & They Stand By Us
“As an ERISA attorney, CPA, and healthcare consultant, I’ve seen organizations claim to deliver payment and cost reduction. ClaimInformatics stands out because they actually delivered on their promises. We highly recommend ClaimInformatics!”
Tony Sorrentino, Chief Compliance Officer, Silverstone Group
“CI’s payment integrity program has helped MLBF identify an extraordinarily large amount of overspending and inefficiency we would otherwise not have found. I’d recommend CI to any funds looking to root out overpayments or inefficiency in health benefit costs”
Lou Mandarini, Administrator, Massachusetts Laborers Benefit Fund
Who's Looking Out For Your Plan?
Without a strong independent partner, like ClaimInformatics, everyone profits from opacity except you and your members.
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TPAs profit from increased claims volume
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Networks collect fees for "negotiating" prices and "cost savings"
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Providers use revenue optimization tactics
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Auto-adjudication prioritizes speed over accuracy
Your Real-Life Blind Spots
What You're Not Seeing Is Costing You
Upcoding Example
Inflating Service Complexity to Increase Reimbursement
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Episode of Care Logic Example
Reviewing claims holistically reveals clear errors
$38K Overpayment - $7.6K Paid By The Member
Example of Hidden Billings
Employer group was unaware that their network was charging a "negotiation fee" for IN-NETWORK claims
$48,000In Hidden Fees
The Fiduciary Duties You Must Uphold
As a health plan fiduciary, your obligation goes beyond simply managing plan assets — it means actively protecting those assets through data access, independent oversight, and compliance with ERISA and CAA requirements.
You can’t meet your fiduciary obligations without your claims data. Access isn’t optional — it’s a legal duty.
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Monitor vendors and payments for errors, hidden fees, and waste
Verify fee reasonableness and enforce contract terms
Safeguard participant data and protect plan assets
Avoid conflicts of interest through independent review
Want to learn more about your responsibilities?