The class action lawsuit filed against Johnson & Johnson was the first of its kind and it changed consultants’ conversations with employers overnight. While the Johnson & Johnson case ultimately fizzled on the basis of legal standing, the Tiara Yachts v. Blue Cross Blue Shield of Michigan case recently took the spotlight and it’s a good one.
June 2025 | Get the latest from the best RBP advocates and auditors
Industry Perspectives
Amy Pellegrin
SVP, Chief Legal Officer
Blue Cross Blue Shield Sued for Mismanagement of Plan Assets
Human resources, company executives and consultants have a lot of fear factor thrown at them these days. Not all of the doomsday is applicable, however, any good steward of a health plan needs to keep themselves informed. Sticking your head in the sand or claiming ignorance will never work out well for your professional career, your company or the members you are responsible for, especially as new lawsuits bring to light existing risks.
The class action lawsuit filed against Johnson & Johnson was the first of its kind and it changed consultants’ conversations with employers overnight. While the Johnson & Johnson case ultimately fizzled on the basis of legal standing, the Tiara Yachts v. Blue Cross Blue Shield of Michigan case recently took the spotlight and it’s a good one. If you have a network, you’ll want to read up and learn from it. There are matters of legal procedure that most will find boring, but the heart of the lawsuit is one every plan sponsor needs to be aware of. Read more.
ClaimTalk
Direct Contracts & Healthcare Pricing Complexities – Part 1
Provider access is the biggest hurdle to successfully implementing a non-traditional health plan. Whether you are utilizing a reference-based pricing strategy or another alternative, direct contracts are almost always utilized to overcome this challenge. Creating direct contracts with providers sounds simple, but doing this correctly is much more complicated than just getting a rate you can live with.
On this month's ClaimTalk, experts Jay Kempton, Shane Cerone and Brad Hansen discuss the complexities of direct contracts and navigating inconsistencies in healthcare pricing.
In this Audit Spotlight, we highlight 10 key coding and billing errors frequently identified on healthcare claims. Ongoing monitoring/auditing of claims is a key element of an effective compliance program. Coding audits identify potential errors and discrepancies to pinpoint specific areas requiring improvement and helps ensure coding guidelines are consistently being followed. Read more.
DirectAccess+ Savings
DirectAccess+™ clients and members achieve maximum protection and savings. To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings. Below is one recent audit result showcasing substantial savings.
Orlando, Florida
Thirteen-day hospital stay for the treatment of cerebral infarction
Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.
Member Experience
Feedback From a Member
"Jaz makes the process so simple! Her response time is lightning fast, and she handles our medical bills with impressive efficiency. She's been incredibly gracious and thorough in getting everything sorted out for us."
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