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
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ClaimInformatics delivers unmatched fiduciary oversight through our proprietary FOCUS framework — ensuring compliance, transparency, and financial integrity.
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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 you and your plan.
True Independence
No revenue from TPAs, networks, PBMs, or providers. Your fiduciary interests come first.
Enterprise Security
SOC 2-certified and HIPAA-compliant platform protects sensitive client data.
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Measurable ROI
Average findings of $500-$1,200 per employee per year. Clear value you can demonstrate.
Fiduciary Alignment
Supports all eight fiduciary duties under ERISA and CAA
compliance requirements.
The Fiduciary Reckoning Is Here
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What wiped out 30% of retirement brokers is now coming for health benefits. See the data, understand the pattern, and position yourself ahead of the curve.
Establish yourself as an essential strategic partner rather than merely a vendor competing on price. ClaimInformatics helps you deliver three key benefits to your clients:
Immediate Cost Recovery
We identify improper payments from the past 1-3 years and recover those funds with zero cost to your clients. Our technology reviews claims against 850+ proprietary rules that standard systems miss.
Ongoing claims monitoring
Beyond recovery, we provide monthly reviews backed by unparalleled analytics, catching errors early before they become a pattern and giving you regular touchpoints to demonstrate your value.​
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Enhanced Fiduciary Protection
Our detailed claim reviews create documentation that helps your clients meet their fiduciary obligations under ERISA - increasingly important as DOL audits intensify.
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ClaimIntelligence™
Setting The Industry Standard for Payment Integrity & Fiduciary Compliance
Our solutions prevent errors before payment, identify risk after payment, and monitor continuously. ClaimInformatics safeguards fiduciary trust at every stage.
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 Guidelines
Industry Guidelines: 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
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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
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?