Read your own claims file.
If your company self-funds its health plan, you are the fiduciary — the same duty of prudence you owe the 401(k). Under ERISA and the Consolidated Appropriations Act of 2021, the claims data is yours by law. Gag clauses that block your access are prohibited, and you signed an attestation saying so.
You don't need to become a claims analyst. You need one afternoon, one spreadsheet, and the five sorts below.
| 03/14 | Smith, J. | CMS-1500 | 99213 · office visit | $92 allowed |
| 03/14 | Smith, J. | UB-04 | G0463 · facility fee | $687 billed |
Same patient, same day, same exam room. The hospital bought the practice — so the visit now bills twice. Most CEOs have never seen the second line. Their employees meet it as a surprise bill.
STEP 1Request the file — these exact fields
Ask your TPA or carrier for a claims extract. De-identified is fine. It must include:
- Claim form type — professional (CMS-1500) vs. facility (UB-04). This one field exposes double billing.
- CPT/HCPCS code and revenue code — what was done, and what the facility called it.
- Place of service (POS) code — where it supposedly happened.
- Billed charge, allowed amount, plan paid, member paid — all four, per line.
- Provider name, NPI, and tax ID — so you can see which health system owns which “office.”
- Date of service and masked member ID — so you can match the two halves of a split bill.
If the answer is “we can't release that,” you have a gag-clause problem — and you attested to CMS that you don't have one.
STEP 2Five sorts that tell you almost everything
Each of these takes about a minute in Excel. Hand the gray line to whoever runs your spreadsheets — it's the literal filter.
1. Find the split bills
One office visit producing two claims — a professional claim and a facility claim, same day, same place — is provider-based billing. The doctor's visit now comes with a building fee.
2. Find office visits coded as hospital outpatient
These are routine office visits placed in a hospital outpatient setting. Every hit is a visit that was — or soon will be — billed with a facility fee.
3. Total the facility fees themselves
That is the facility fee. Count them. Total them. This is the number nobody has shown you.
4. Get your multiple of Medicare
That multiple — 200%? 400%? 900%? — is the single best measure of what your “discount” is actually worth.
5. Read your top 20 claims, cold
A handful of claims typically drive half your spend. You should be able to say what each of the top 20 was and why it cost what it did.
STEP 3The pocket benchmarks — what Medicare pays
Approximate 2026 national rates. The point isn't the pennies — it's the multiple.
| Service | Physician fee | Hospital facility fee | Medicare all-in |
|---|---|---|---|
| Office visit — physician office 99213 | ~$92 | none | ~$92 |
| Same visit — hospital-owned clinic 99213 + G0463 | ~$92 | ~$52–129 | ~$145–220 |
| ER visit, level 5 99285 | ~$162 | ~$630 | ~$790 |
| MRI, lumbar spine 72148 | incl. | ~$260 | ~$260 |
| Colonoscopy with polyp removal 45385 | ~$265 | ~$1,550 | ~$1,815 |
| Cataract surgery 66984 | ~$535 | ~$2,270 | ~$2,805 |
| Outpatient knee replacement 27447 | ~$1,150 | ~$12,700 | ~$13,850 |
National averages before locality adjustment — verify exact figures at the CMS fee schedule lookup. If your plan paid $6,500 for a $1,815 colonoscopy episode, that's 358% of Medicare, and someone agreed to it on your behalf.
STEP 4Five questions your broker and TPA should answer on the spot
- What percentage of our office visits carry a facility fee, and what did those fees total last year?
- What multiple of Medicare are we paying — overall, and at each health system?
- Can I have my complete claims file, with revenue codes and place of service, by Friday?
- What are you paid, in total — direct and indirect — for this plan? Then check it against Schedules A and C of your own Form 5500.
- What in our plan document or network contract actually requires us to pay a facility charge on a routine office visit?
Hesitation on any of these is itself an answer.
Why this is your job
Plan assets are being spent under your fiduciary duty. Recent lawsuits against major employers are built on one theory: you could have looked, and you didn't. Ignorance used to be a shield. The CAA turned it into evidence.
Take the tools
No email address. No form. No follow-up sequence. Print it, forward it, hand it to your CFO — that's what it's for.