Austin Johnson
Head of Customer Success, Wellnecity
Contract Terms Can Make — or Break — Fiduciary Oversight
When a single claim can exceed $1M, employers need more than just a network — they need visibility, leverage, and protection.
Yet too often, critical data is out of reach. Why? Because most TPA and ASO contracts don't guarantee access to detailed claim information — especially for high-dollar cases. Without it, employers and their fiduciary partners are left exposed to unchecked billing and little recourse under the No Surprises Act (NSA) and Independent Dispute Resolution (IDR) processes.
At Wellnecity, we've seen numerous instances where lack of contractually guaranteed data access has left employers unable to validate or contest high-dollar claims. In one example, a $1.3M claim was paid in full because the administrator lacked the contractual rights to obtain detailed billing information — eliminating any opportunity for review or negotiation.
What Can Be Done?
Employers must take proactive steps to strengthen contractual protections and reclaim oversight:
- Add contract language requiring automated delivery of claim details for charges over $100K
- Establish clear data access, audit, and recovery rights in administrative services contracts
- Leverage patient access rights as a tool to support fair reimbursement and reduce exposure under the No Surprises Act and IDR
We work closely with companies who support employers as co-fiduciaries — offering bill reviews and defending plan assets, often only charging when dollars are recovered.
Fiduciary oversight isn't just a compliance checkbox. It's a duty — and a strategy. Let's make sure your contracts are working as hard as you are.
