ClaimInformatics drops shared-savings pricing for flat per-claim fees

ClaimInformatics unveiled a new pre-pay pricing model, litigation tracker and fiduciary playbooks aimed at self-funded employers, brokers and TPAs. The company says the changes are designed to reduce ERISA conflict-of-interest risks as health-plan fiduciary scrutiny intensifies.

Why it matters: - ClaimInformatics is targeting a core conflict in payment integrity pricing: vendors paid on savings have a financial incentive to deny more claims. - The company is pitching a flat, per-claim fee as easier for self-funded plan fiduciaries to defend under ERISA §408(b)(2). - The launch comes as health-plan fiduciaries face rising litigation and regulatory pressure, including scrutiny of vendor compensation.

What happened: - ClaimInformatics announced a new Pre-Pay pricing model built on a flat, per-claim fee. - The company said the model removes percentage-of-savings and per-employee-per-month, or PEPM, pricing from its pre-pay platform. - The announcement came with a redesigned website that includes a Self-Funded Plan Litigation and Regulatory Tracker and three fiduciary playbooks. - The company said the materials are aimed at self-funded employers, benefits consultants and brokers, and third-party administrators.

The details: - Every claim reviewed through the Pre-Pay platform is checked against ClaimInformatics’ edit library for a fixed fee. - The company said there is no dollar threshold and no charge tied to the review outcome. - ClaimInformatics said the structure is intended for self-funded plans, captives and independent TPAs. - The company said the flat-fee model replaces compensation structures that have dominated payment integrity for two decades. - ClaimInformatics argued that percentage-of-savings pricing can create a structural conflict because a vendor gets paid more when more claims are denied. - The company said a flat per-claim fee pays for the review itself, not the result. - ClaimInformatics said the model is designed to be more defensible as reasonable compensation under ERISA. - The litigation and regulatory tracker follows 44 milestones across litigation, reimbursement disputes, state activity, agency rules and statutes affecting self-funded plans, captives, public-sector plans and church plans. - The tracker includes a Fiduciary Pressure Index that currently rates the environment as EXTREME. - The milestones map to ERISA, PHSA, CAA and MHPAEA, and to plan contract types including SPD, ASO, PBM and stop-loss. - Recent additions include ERISA §726, added by CAA 2026, which codifies PBM compensation monitoring as a statutory duty. - The tracker also cites Tiara Yachts v. Blue Cross Blue Shield of Michigan, where the Sixth Circuit said a TPA with discretionary authority over claims can be a functional fiduciary under ERISA §3(21) and face personal liability under §409. - The TPA Fiduciary Playbook focuses on ERISA §3(21) exposure for independent TPAs and outlines a white-label model for conflict-free oversight. - The Broker Fiduciary Reckoning draws a parallel to the 401(k) fee-disclosure wave after the 2012 DOL rules and says CAA 2021 broker-disclosure requirements are pushing fee compression and consolidation in health benefits. - Fiduciary Compliance Through Payment Integrity is aimed at self-funded employers and organizes guidance around the eight ERISA fiduciary duties. - ClaimInformatics said the new website, tracker, playbooks and pricing model are available at claiminformatics.com. - The company said self-funded employers, TPAs, captives and benefits consultants can request a complimentary ASO analysis through the site.

Between the lines: - The launch is as much a positioning move as a product update. - ClaimInformatics is aligning its pricing, content and compliance tools around one message: claims oversight should be independent of claims savings. - The company is also trying to make fiduciary risk visible and continuous, not a once-a-year compliance exercise. - The broader bet is that employers and their advisers will pay for tools that help document prudence before disputes, audits or lawsuits arise.

What's next: - ClaimInformatics is using the website launch to drive adoption of its Pre-Pay platform and ASO analysis offering. - The tracker will likely continue to expand as litigation, agency guidance and state activity evolve. - The playbooks appear designed to support sales conversations with employers, brokers and TPAs while the fiduciary debate accelerates. - Stephen Carrabba said the company wants to give plan sponsors, brokers and TPAs a citable answer before regulators or plaintiffs demand one.

The bottom line: - ClaimInformatics is betting that flat-fee claim review, paired with fiduciary compliance tools, will resonate in a market where shared-savings pricing is increasingly a liability, not a feature.