As I reflect on 20 years in the employee benefits industry, it’s evident that human resources has been the one to decide who plays and who doesn’t in the benefits world. It’s clearer now that the strategy for many solutions wasn’t to give HR what they needed; it was to give them something that looked good during warmups.
July 2025 | Get the latest from the best RBP advocates and auditors
Industry Perspectives
Shay Butler
Vice President of Business Development
The New Playbook —
Manipulating HR
This year marks my 20th year in the employee benefits industry. It’s hard to believe two decades have passed since I took my first steps into employer-sponsored benefits — a world that continues to evolve and leave me scratching my head for answers, which has way less hair on it than it did 20 years ago. As I reflect back, it’s evident that human resources has been the one to decide who plays and who doesn’t in the benefits world. It’s clearer now that the strategy for many solutions wasn’t to give HR what they needed; it was to give them something that looked good during warmups. Read more.
ClaimTalk
Direct Contracts & Healthcare Pricing Complexities – Part 2
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, experts 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.
Mystery Markups: CT Scan Charges Vary Across Hospitals
There are numerous CPT codes to consider when reporting and billing CT scan services, depending on the area of the body being imaged, whether performed without contrast, with contrast or without contrast followed by contrast and further sections/sequences. Additionally, CT scans may be considered a “global” service code (encompassing both the technical component and professional component reported with no modifier), a professional component-only service (reported with modifier 26) or a technical component-only service (reported with modifier TC).
In this Audit Spotlight, we focus on egregious hospital charges identified on claims specific to CT scan services. 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.
Muskogee, Oklahoma
Five-day hospital stay for the treatment of left tibial/fibula fracture due to a fall and related surgery
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
"Erick took the time with me on the phone to go through my difficult claims and understand the separation of each claim. He was patient with my confusion at the statements and was able to lighten the mood."
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