You Can’t Oversee What You Can’t See

Most self-funded plans see their claims only after they are paid.

Your TPA or carrier adjudicates a claim, pays it, and reports it to you later. By then, any error is a refund you have to chase, if it is recovered at all. Many Bolton clients now send pre-paid, post-adjudicated claims daily to an independent claims integrity vendor, which checks every line for pricing errors, unbundling, incorrect coding and fee-schedule violations before payment.¹

Across participating clients, the gross claim error rate has averaged 10% to 12%. One plan that put every claim before an independent claims integrity vendor prior to payment avoided $1.6 million in overpayments in a year.¹ This reduced their total $16 million in annual medical spend down to $14.8M, net of fees for the independent vendor.¹

Source: Bolton Innovation Group claims integrity case study, 36,232 claims dated Oct. 28, 2024 to Oct. 27, 2025

So, if there is a clear path to plan savings with low member impact and minimal administrative lift, why is this practice not more widespread? The barrier is access. TPAs have embraced this review, but ASO carriers have resisted sharing pre-paid claims.¹ Employers are only recently understanding their ability to mandate a full claims review by an independent third party. It will take some resolve, but these are your dollars.

Implications for you

• Ask who reviews your claims before they are paid, and whether that reviewer is independent.
• If your carrier won’t share pre-paid claims, start after payment. One Bolton ASO Client now sends every paid claim of $25,000 or more to an independent reviewer each month.¹
• Expect insight, not just refunds. Your plan’s billing-pattern findings will shape the next fee-schedule negotiation.

Request a Claims Review. Using a template we can provide, send us 12 to 18 months of paid claims. In eight weeks, you’ll have a payback report showing what was paid incorrectly and how to recover it. Contact Liz Gardner at lgardner@boltonusa.com or (443) 798-8586.

Sources

1. Bolton Innovation Group, Strengthening Fiduciary Performance Through Claims Integrity (case study; claims dated Oct. 28, 2024 to Oct. 27, 2025)