PLANSPONSOR Roadmap: Data-Driven Decisions—Let’s Talk Payment Integrity

Executives and advisers in the health benefits sector described a system still shrouded in opacity, even after federal efforts to force transparency, during the second session of the 2026 PLANSPONSOR Roadmap: Health Benefit Fiduciary Duties livestream series.

The speakers delivered a blunt warning to employers: Without greater access to data and the resolve to question vendors, companies risk wasting millions and increasing their exposure to legal liability.

“Health care costs are continuing to rise at levels that are unsustainable,” said Jamie Greenleaf, moderator of the webinar and co-founder of Fiduciary In A Box. “So the government has really stepped in to provide us with additional transparency around cost and quality on our health care plans.”

Yet several speakers said that promise has not yet translated into practice.

A Transparency Gap

The discussion centered on the lingering disconnect between what employers are entitled to under laws such as the Consolidated Appropriations Act of 2021 and what they can actually obtain from insurers and administrators.

Stephen Carrabba, president of ClaimInformatics Ltd., said employers often believe they have sufficient data until they try to use it.

“Typically we find that clients are telling us all the time, ‘Hey, we have access to all of our plan data,’” he said during the webinar. “Great. Send us the record layout, and lo and behold, it’s 45—maybe 50—different data elements,” far short of what is needed to evaluate claims accuracy. “You really need north of 150 to 200 different data elements.”

Without that level of detail, experts warned, employers cannot fulfill their fiduciary duties under the Employee Retirement Income Security Act, including monitoring service providers and ensuring fees are reasonable.

Contracts Under Scrutiny

A recurring theme of the discussion was that plan sponsors’ problems often begin in contracts, particularly administrative services agreements that govern how third-party administrators handle claims.

Carrabba described provisions that allow vendors to retain savings from correcting overpayments or that limit their financial liability, even when errors occur.

“This is saying I am going to potentially improperly pay a claim because I’m not doing my job properly the first time, and if, in fact, I identify any recoupments, I actually get to keep 100% of those overpaid plan assets,” he said. “Talk about a prohibited transaction.”

Such clauses, he argued, may violate federal fiduciary standards, even if employers are unaware of them.

Real-World Costs

Alan Gilbert, senior vice president of business strategy at 4C Digital Health, offered a concrete example of how hidden inefficiencies can translate into significant losses for plan sponsors or participants.

In one case, he said, a national provider manipulated billing practices in a way that triggered higher reimbursement rates, costing an employer roughly $500,000 in additional fees.

“These figures would have not otherwise been seen if you didn’t have this unbiased, independent review,” Gilbert said.

He added that many large employers are beginning to take a more active role in overseeing their health plans: “There is a fiduciary shift that’s fundamental going on,” he said.

Data That Do Not Add Up

For smaller employers and advisers, the challenge can be even more basic than described by the other speakers. Sometimes, the data received by smaller companies or their advisers may simply be incomplete or unusable.

Patrick Moore, who advises plan sponsors on their health plan fiduciary duties as CEO and co-founder of Pretekt, described receiving two separate data files from a carrier—one with patient information but no costs, and another with costs but no identifying details. The inconsistencies extended further. One dataset suggested $52 million in claims, while broker reports to the plan sponsor showed $15 million, and carrier summaries showed $18.9 million.

“Someone tell me what the hell I paid,” Moore said.

Even when employers do obtain data, it may lack critical details, such as the quantities of prescription drugs purchased or necessary billing codes, making it difficult to identify overspending, particularly in high-cost areas such as specialty drug infusions.

Resistance Persists

Speakers said that despite the formal elimination of “gag clauses” that once restricted data-sharing to insurers from providers, insurers and administrators continue to erect barriers.

“They’re kind of getting around the legislation and just still not giving you the data you need,” Moore said.

Those barriers can include claims of proprietary information, cybersecurity requirements or high fees for data access—hurdles that often deter employers from pressing further.

Even so, the panelists pointed to signs of change. Employers, consultants and even finance executives are becoming more engaged as health care costs climb. The rise in litigation related to fiduciary responsibilities is also accelerating that shift, the experts noted.

What Employers Can Do Now

The panelists offered a consistent set of recommendations for plan sponsors: scrutinize contracts, demand detailed data and, where possible, enlist independent analysts.

It all starts with the request for proposals and the contract language, Carrabba said.

Gilbert emphasized the need to understand current spending in a company’s plan before making changes: “You can’t govern what you can’t see.”

Moore urged employers to start small, if necessary, even by examining specific billing codes to identify high-cost areas.

“This is not just transforming employers and how they look at their risk,” Gilbert said. “Every sector in the health care economy is carrying risk from this that they’re not even aware of.”