For a full transcript of this episode, click here.
On the show today, I am going to use the term TPA (third-party administrator) and ASO (administrative services only) vendor kind of interchangeably here. But these are the entities that a plan sponsor—for example, a self-insured employer is a plan sponsor—but these plan sponsors will use to administer their plan. And one of the things that TPAs and ASOs administer is this so-called weekly claims wire.
Every week, self-funded employers get a weekly claims run charge so they can pay expenses related to their plan in weekly increments. The claims run usually comes with a register or an invoice. This invoice might be just kind of a total (“Hey, plan. Pay this amount.”). Or there might be a breakdown like, “Here’s your medical claims, and here’s your pharmacy claims.” Maybe there’s another level down from that of detail if the plan or their advisor is sophisticated enough and/or concerned enough about the fiduciary risk to dig in hard about what the charges are actually for.
I was talking about this topic earlier with Dana Erdfarb, who happens to be executive director of HR at a large financial services organization. Dana I’m definitely gonna credit for inspiring this conversation that I’m having today with Justin Leader. Dana was the first one to really bring to my attention just the level of hidden fees that are buried (many times) in these claims wires … because when I say buried in the claims wire, I mean not charged for via an administrative invoice. These hidden fees are also not called out in the ASO finance exhibit in the contract, by the way. So, yeah … hidden.
I don’t know … if you have to hide your charges, in my mind that’s a pretty big tell that your charges are worth hiding. Now the one thing I will point out is that just because the charges are worth hiding doesn’t necessarily mean that the services those charges are for are unwarranted. Some of these services are actually pretty worthwhile to do. There’s just a really big difference from a plan sponsor knowingly contracting at a known rate with a third party to do something versus paying for a service knowingly or unknowingly via fees hidden in a claims wire wherein the amount paid is not in the control of the one paying the bill.
Anyway, I was talking about all of this earlier, as I mentioned, with Dana Erdfarb. That conversation was exactly the framework that I needed to snag Justin Leader, my guest today, to come on the pod and really dig into the detail level of what’s going on with this claims wire. So, in this healthcare podcast, we’re gonna talk about the five fees that tend to be tucked in to many claims wires. We also talk about one bonus—not sure if it’s a fee—one bonus way that plan sponsors give money to vendors in ways the plan sponsor might be unaware of. Here are the five hidden fees that we talk about at length in the show today, and then I’ll cover the bonus:
1. Shared Savings Fees. This is where a member of a plan goes out of network, and the TPA/ASO goes and negotiates a discount from the out-of-network provider and then shares the savings. Get it? Shared savings? This category also might include BlueCard Access fees, which we talk about in the show. But there also could be overpayment recoupment fees lumped in here. This is where the TPA messes up, overpays, and then charges the plan sponsor a percentage of the money they just got back when they corrected their own mistake. I’m just gonna pause here while everyone contemplates how we’ve all gone so wrong in life to not have figured out a way to charge others when we correct our own mistakes. Here’s a link to a great LinkedIn post by Chris Deacon and a deep dive article on this topic.
2. Prior Auth Fees. Lots to unpack with this one, which Justin does in the pod.
3. Prepayment Integrity Fees. This is evaluation of the claim before it’s being paid. Listen to the show for how this may (or may not) differ from what the TPA/ASO is supposed to be doing (ie, it’s the TPA that’s supposed to be [yeah, right] adjudicating and paying claims).
4. Pay and Chase Fees. This is where a bill was paid wrong, and it’s not immediately the TPA/ASO’s mistake. This is where something like a provider double billed or overcharged or something, and the TPA/ASO later figures this out and then chases the pay to get the money back.
5. TPA Claims Review Fees. Sort of self-explanatory but also not. Again, please listen to the show for more.
When I’d been talking about all of this with Dana Erdfarb, as I mentioned earlier, just about this whole thing, she said something that Justin Leader echoes today: Many of these fees are structured as a percentage of savings. This is challenging for a plan sponsor because the savings is vendor reported and not validated. But it also means that if the savings increase annually with trend (as they, generally speaking, do), then the fees will increase with that trend as well—and that is something to keep in mind.
Okay … so, here’s the bonus thing that didn’t get a number in the show today, but it is certainly a way that plan sponsors pay money to vendors. And this is medical claims spread pricing. This is buried in the claims wire and inside the dollar amounts the plan sponsor thinks they are paying a provider for a service. It turns out that it can turn out that the amount the plan sponsor is paying is more than the check that’s being written to the provider for the service being delivered. Or the amount the plan sponsor is paying the provider for a service is more than for simply that service that has been rendered, right? The plan sponsor is paying the provider for other stuff as well, as is alleged in the DOL v BCBS of Minnesota lawsuit, which Justin brings up in the show today.
It drives me nuts, honestly, when there are people who tout their transparency. But then it turns out if the equation is A plus B equals C, only like one of the numbers is transparent. Sorry, functionally, that doesn’t count as transparency except in marketing copy.
This is all to say—and here’s Dana Erdfarb’s actionable advice which sums up points Justin also made—when employers review their medical plan vendor contracts, they should make sure to identify, review, and document all fees being paid to their vendors and incorporate this knowledge into their renewal/RFP (request for proposal) discussions and negotiations.
Jeff Hogan echoed this advice on LinkedIn the other day when he commented on this show: “Such a great opportunity for employers to have their administrative services agreements and other documents examined to discover these schemes. It’s not hard to do. Also, a great advertisement for the value of having retrospective audits performed. It is eye opening to see not only the amount of arbitrage but often how payers don’t even pay according to their contracts. Justin Leader is the perfect guest.”
As mentioned a myriad of times already, my guest today is Justin Leader, who is president and CEO of BenefitsDNA. Justin works with plan sponsors, both commercial plans as well as Taft-Hartley plans, across the United States.
Before we kick into the show today, I just want to thank By the 49ers for the really nice review on iTunes. By the 49ers calls Relentless Health Value a “leading voice in healthcare” and says he or she always leaves “with intrigue, a new idea or a new approach to problem solving.” Really appreciate that. That is certainly one of our goals around here. So, thank you so much.
Oh, also, please subscribe to the weekly email that goes out. You can do that by going over to our Web site and signing up. There are a lot of advantages to doing so, which I’ve talked about before, so I’m not gonna do so again; but it is a great way to make sure that if you’re a member of the Relentless Health Value Tribe, you are aware of the current goings-on.
Also mentioned in this episode are Dana Erdfarb, Chris Deacon, Jeffrey Hogan, BenefitsDNA, Rik Renard, Cora Opsahl, Al Lewis, Julie Selesnick, Mark Davenport, Karen Handorf, Dawn Cornelis, AJ Loiacono, and Mike Miele.
You can learn more at benefitsdna.com or wefixyourhealthcare.com.
You can also follow Justin on LinkedIn.
Justin Leader began his career in the pharmaceutical and financial services industries. By 2011, Justin entered into the group benefits field consulting for many notable Fortune 500 clients.
In 2014, he established BenefitsDNA, an objective, independent health and welfare benefit plan consulting firm providing compliance oversight, actuarial services, cost mitigation, and traditional broker services to Group Health Plan Sponsors. As a Certified Health Rosetta Chartered Advisor (eighth advisor to join), he’s acknowledged for contributing to healthcare solutions in the United States both in policy as well as practice and is an avid supporter of Patient Rights Advocate.
Throughout his career, Justin has been instrumental in introducing successful healthcare benefit solutions to the market, which have been pivotal in solving critical issues and saving millions for employers and their employees.
As a mission-driven leader, he and his team are passionate about fixing healthcare one client, one member, and one partnership at a time. Having trademarked We Fix Your Healthcare™, their mission is one that his team takes seriously.
Justin, a native of Bedford, Pennsylvania, holds a pre-medicine degree and a master’s degree in exercise science from California University of Pennsylvania. His dedication extends to servant leadership, volunteering in the local community including serving on the PA State Council of SHRM (Society for Human Resource Management) since 2016. Justin is a public speaker and owner of Leaders Never Quit, where he dedicates his time to inspiring others with a message of hope, humor, and resilience.
07:55 How is the claims wire typically explained to a plan sponsor?
11:18 What is the whole point of self-funding?
11:27 Why is it so vital to understand what you’re paying for?
12:38 What are the five “buried” items that wind up in these claims wires?
13:03 What is a shared savings fee?
17:10 “Rates are important, but so are your rights.”
21:01 What’s going on with prior auth fees?
23:35 What is prepayment integrity?
28:16 What is pay and chase?
31:54 What is a TPA claim review?
35:47 Is there medical claim spread pricing?
You can learn more at benefitsdna.com or wefixyourhealthcare.com.
You can also follow Justin on LinkedIn.
@JustinDLeader discusses #plansponsor #payments on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation
Recent past interviews:
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Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia
00:00:00
Episode 433, "The Mystery of the Weekly Claims Wire.
00:00:06
What Are Plan Sponsors Actually Paying For Each Week?"
00:00:10
Today, I speak with Justin Leader.
00:00:21
American Healthcare Entrepreneurs and Executives You Want to Know Talking.
00:00:27
Relentlessly Seeking Value.
00:00:29
On the show today, I am going to use the term TPA, Third Party Administrator, and
00:00:35
ASO, Administrative Services Only vendor, kind of interchangeably here, but these
00:00:40
are the entities that a plan sponsor, for example, a self insured employer is
00:00:45
a plan sponsor, but these plan sponsors will use to administer their plan.
00:00:50
And one of the things that TPAs and ASOs administer is this
00:00:55
so called weekly claims wire.
00:00:57
Every week, self-funded employers get a weekly claims run charge.
00:01:03
So they can pay expenses related to their plan in weekly increments.
00:01:08
The claims run usually comes with a register or an invoice.
00:01:12
This invoice might be just kind of a total.
00:01:14
Hey plan, pay this amount.
00:01:16
Or there might be a breakdown, like here's your medical claims.
00:01:19
And here's your pharmacy claims.
00:01:21
Maybe there's another level down from that of detail, if the plan or
00:01:25
their advisor is sophisticated enough and or concerned enough about the
00:01:28
fiduciary risk to dig in hard about what the charges are actually for.
00:01:34
I was talking about this topic earlier with Dana Erdfarb, who happens to be
00:01:38
executive director of HR at a large financial services organization,
00:01:43
Dana, I'm definitely going to credit for inspiring this conversation that
00:01:47
I'm having today with Justin Leader.
00:01:50
Dana was the first one to really bring to my attention just the
00:01:53
level of hidden fees that are buried many times in these claims wires.
00:01:59
Because when I say buried in the claims wire, I mean not charged
00:02:04
for via an administrative invoice.
00:02:07
These hidden fees are also not called out in the ASO finance
00:02:11
exhibit in the contract, by the way.
00:02:13
So yeah, hidden.
00:02:15
I don't know if you have to hide your charges.
00:02:17
In my mind, that's a pretty big tell that your charges are worth hiding.
00:02:21
Now, the one thing I will point out is that just because the charges
00:02:24
are worth hiding doesn't necessarily mean that the services those
00:02:28
charges are for are unwarranted.
00:02:32
Some of these services are actually pretty worthwhile to do.
00:02:35
There's just a really big difference from a plan sponsor knowingly contracting
00:02:40
at a known rate with a third party to do something versus paying for
00:02:45
a service knowingly or unknowingly via fees hidden in a claims wire,
00:02:49
wherein the amount paid is not in the control of the one paying the bill.
00:02:53
Anyway, I was talking about all of this earlier, as I mentioned with Dana Erdfarb.
00:02:58
That conversation was exactly the framework that I needed to snag Justin
00:03:02
Leader, my guest today, to come on the pod and really dig into the detail level
00:03:06
of what's going on with this claims wire.
00:03:08
So today we're going to talk about the five fees that tend to
00:03:11
be tucked into many claims wires.
00:03:14
We also talk about one bonus, not sure if it's a fee, one bonus way that plan
00:03:19
sponsors give money to vendors in ways the plan sponsor might be unaware of.
00:03:25
Here are the five hidden fees that we talk about at length in the show
00:03:29
today, and then I'll cover the bonus.
00:03:31
First hidden fee is the shared savings fees.
00:03:34
This is where a member of a plan goes out of network and the TPA/ASO
00:03:40
goes and negotiates a discount from the out of network provider
00:03:44
and then shares the savings.
00:03:47
Get it?
00:03:47
Shared savings.
00:03:48
This category also might include BlueCard access fees, which we talk about in the
00:03:53
show, but there also could be overpayment recoupment fees lumped in here.
00:03:57
This is where the TPA messes up, overpays, and then charges the plan sponsor a
00:04:03
percentage of the money they just got back when they corrected their own mistake.
00:04:07
I'm just going to pause here while everyone contemplates how we've all
00:04:11
gone so wrong in life to not have figured out a way to charge others
00:04:14
when we correct our own mistakes.
00:04:16
Second, hidden fee, prior auth fees, lots to unpack with this
00:04:21
one, which Justin does in the pod.
00:04:24
Number three are prepayment integrity fees.
00:04:28
So this is evaluation of the claim before it's being paid.
00:04:31
Listen to the show for how this may or may not differ from what the
00:04:35
TPA/ASO is supposed to be doing, i.e.
00:04:38
it's the TPA that's supposed to be, yeah, right, adjudicating and paying claims.
00:04:44
Pay and chase fees, this is the fourth kind of fee.
00:04:46
This is where a bill was paid wrong, and it's not immediately
00:04:51
the TPA/ASO's mistake.
00:04:54
This is where something like a provider double billed or overcharged or something.
00:05:00
And the TPA/ASO later figures this out and then chases the pay to get the money back.
00:05:08
And then five TPA claims review fees, sort of self explanatory, but also not.
00:05:13
Again, please listen to the show for more.
00:05:15
When I've been talking about all of this with Dana Erdfarb, as I mentioned earlier,
00:05:19
just about this whole thing, she said something that Justin Leader echoes today.
00:05:22
Many of these fees are structured as a percentage of savings.
00:05:26
This is challenging for a plan sponsor because the savings is
00:05:30
vendor reported and not validated.
00:05:32
But it also means that if the savings increase annually with trend, as they
00:05:37
generally speaking do, then the fees will increase with that trend as well.
00:05:41
And that is something to keep in mind.
00:05:43
Okay, so here's the bonus thing that didn't get a number in the show
00:05:47
today, but it is certainly a way that plan sponsors pay money to vendors.
00:05:51
And this is medical claims spread pricing.
00:05:55
This is buried in the claims wire and inside the dollar amounts
00:05:58
the plan sponsor thinks they are paying a provider for a service.
00:06:02
It turns out, but it can turn out, that the amount the plan sponsor
00:06:06
is paying is more than the check that's being written to the provider
00:06:10
for the service being delivered.
00:06:12
Or the amount the plan sponsor is paying the provider for a service.
00:06:16
Is more than for simply that service that has been rendered right?
00:06:21
The plan sponsor is paying the provider for other stuff as well, as is alleged
00:06:25
in the DOL vs BCBS of Michigan lawsuit, which Justin brings up in the show today.
00:06:31
It drives me nuts, honestly, when there are people who tout their transparency.
00:06:37
But then it turns out if the equation is A plus B equals C, only like
00:06:42
one of the numbers is transparent.
00:06:44
Sorry, functionally, that doesn't count as transparency, except in marketing copy.
00:06:50
As mentioned a myriad of times already, my guest today is Justin Leader, who
00:06:55
is president and CEO of BenefitsDNA.
00:06:58
Justin works with plan sponsors, both commercial plans as well as Taft
00:07:01
Hartley plans across the United States.
00:07:03
Before we kick into the show today, I just want to thank ByThe49ers for
00:07:06
the really nice review on iTunes.
00:07:09
ByThe49ers calls Relentless Health Value a leading voice in healthcare and says he
00:07:15
or she always leaves with intrigue, a new idea or a new approach to problem solving.
00:07:20
Really appreciate that.
00:07:21
That is certainly one of our goals around here.
00:07:24
So thank you so much.
00:07:25
My name is Stacey Richter.
00:07:26
This podcast is sponsored by Aventria Health Group.
00:07:29
Oh, also, please subscribe to the weekly email that goes out.
00:07:33
You can do that by going over to our website and signing up.
00:07:37
There are a lot of advantages to doing so, which I've talked about before, so I'm not
00:07:41
going to do so again, but it is a great way to make sure that if you're a member
00:07:45
of the Relentless Health Value Tribe, you are aware of the current goings on.
00:07:50
Justin Leader, welcome to Relentless Health Value.
00:07:52
Stacey Richter, thank you for having me.
00:07:55
Let's talk about this claims wire here.
00:07:57
First of all, how is this claims wire typically explained?
00:08:02
So if I'm a typical self insured plans sponsor, someone's probably
00:08:07
going to tell me that this claims wire is going to happen.
00:08:09
Maybe it's the broker that's explaining on behalf of the ASO, but how does that
00:08:16
typical explanation go down in short?
00:08:18
Typically the explanation is you're going to go from paying monthly
00:08:23
claims or invoices to paying a weekly claims run, and there'll be some
00:08:26
fluctuation, but we can budget for that.
00:08:29
Now I'm role playing the plan sponsor.
00:08:31
So you're just gonna draw from my bank account.
00:08:35
What happens here?
00:08:36
Each week we're going to hit you with a claims register.
00:08:38
You're going to take a look at that and then you're going to
00:08:40
approve those claims to be paid.
00:08:43
Some weeks they'll be low, some weeks they'll be high.
00:08:45
So claims, I'm told I'm paying claims?
00:08:48
You're paying claims.
00:08:49
You're paying medical and prescription claims.
00:08:52
Typically on the same register.
00:08:54
This is going to be really good for you, Mr.
00:08:56
and Mrs.
00:08:56
Plan Sponsor, because you'll be able to understand what's going on within your
00:09:01
plan on a week to week basis by the invoice amount that you're going to pay.
00:09:06
So, on my invoice, if I'm looking at a sample of one of
00:09:09
these, what do I actually see?
00:09:11
What is on there?
00:09:12
A list of all of my claimants with their claims and all the drugs I paid?
00:09:16
Stacey, you're asking a lot of questions.
00:09:19
It really depends.
00:09:20
It depends on the administrator.
00:09:22
You may get very, very basic information like, here's your
00:09:26
medical claims for the week.
00:09:27
Here's your Rx claims for the week.
00:09:29
Sometimes, you might get a little bit more detail.
00:09:33
You might get claimant information, you might get maybe member ID, claim
00:09:38
number, date of service and paid amount.
00:09:40
If you get a little bit better information, you're going to get the
00:09:43
type of service, provider information, the charged amount, the paid amount,
00:09:47
claim status, but ultimately it's up to you as the plan sponsor or
00:09:52
as the advisor in certain instances to push for that information.
00:09:55
This wire is an amount that is paid by the plan on a weekly basis.
00:10:01
Plans are told, okay, well, these are for your actual claims.
00:10:05
I mean, there's other payments that are going on, which are supposed to be, which
00:10:09
are for administrative stop loss, right?
00:10:11
Like, so I mean, there's other bills, which are happening, but
00:10:14
what this wire is supposed to be is to pay for actual claims.
00:10:18
Did I get that right?
00:10:19
You got that.
00:10:20
Absolutely correct.
00:10:21
I have to say, Justin, one of the reasons why I asked you to come on this podcast
00:10:26
and talk about this topic is because I have gotten so many requests from plan
00:10:33
sponsors who say to me, I'm getting this invoice and it's got to your exact point
00:10:41
some level of detail, but I don't know much and I'm feeling like I actually
00:10:45
keep asking, what am I paying for here?
00:10:48
And bottom-line, I can't figure it out.
00:10:51
It feels like there's other stuff that's going on here.
00:10:53
Someone will allude to something else that I'm paying for, but I
00:10:56
just cannot get any details here.
00:11:00
And I think that's part of the major issue.
00:11:02
Employers go to self-funding because they want to feel like they're more
00:11:05
in control They want to be able to glean insights and look at data.
00:11:10
However, by virtue of moving self-funded, it doesn't mean that you're going to have
00:11:14
all this unencumbered access to data.
00:11:17
I guess keep in mind too, like the whole point of this or self-funding in general
00:11:23
is to be able to take actionable insights.
00:11:25
So that's a big topic of discussion in itself.
00:11:27
But, there's a lot of stuff that's buried in the claim that can go on.
00:11:31
And that's why it's so, so vital to understand what
00:11:34
the heck we are paying for.
00:11:36
This is an opportunity really, this claims wire, because you don't have
00:11:41
to wait till the end of the year to figure out that a lot of money got
00:11:44
spent that now you can do nothing about.
00:11:47
If there is a right sized amount of data that is in the claims wire that comes
00:11:51
across just even relative to the claims, irrespective of everything else, then this
00:11:56
is actionable information that this kind of black box starts to become more clear.
00:12:03
And if it's a black box, the solution is also a black box,
00:12:07
right, as Rick Renard has said.
00:12:09
And the thing is the black box is sometimes buried in the middle of the
00:12:13
Pacific Ocean and you have to really dig down to get to that level of detail.
00:12:17
But on the surface, the beauty of it is you can start to take some action.
00:12:21
The unfortunate thing is not all claims runs are created equal.
00:12:24
Not all claims runs provide the level of detail that you want regarding what
00:12:29
should be common, like the example that I just gave, but even more specifically,
00:12:33
some of the buried fees that you have no idea are being incurred within the plan.
00:12:38
All right, so let's talk about these buried fees.
00:12:40
Exactly what are all of the things?
00:12:43
There are five things.
00:12:45
Shared savings fees.
00:12:47
We have prior authorization fees.
00:12:49
We have prepayment integrity.
00:12:52
We have pay and chase.
00:12:53
Then we have the bare bones basic, which is the TPA that's doing the adjudication.
00:12:58
Okay, so taking it from the top.
00:13:00
Let's talk about shared savings fees.
00:13:02
So first of all, what is a shared savings fee?
00:13:06
Shared savings fee is a fee that is taken by the administrator, or another
00:13:10
point solution for helping to reduce that charge within the claims run.
00:13:17
So it could be an out of network provider fee, that's typically the most common.
00:13:22
One of my members goes to an out of network ER or something, right,
00:13:29
or just an out of network place.
00:13:31
I pay some exorbitant amount.
00:13:35
The TPA goes to that out of network place, negotiates a 50 percent
00:13:41
discount, and then gets a percentage of whatever the new discounted rate was.
00:13:47
And it could be even something as common as BlueCard access fees, right?
00:13:53
You're going into another Blue's network utilizing a Blue and you're
00:13:56
going to get pinged for a fee for entering into another Blue territory.
00:14:00
Basically, I have a Blue's plan if I'm, if I'm a member here.
00:14:04
And my plan has a contract with my 10 local hospitals or whatever, but a
00:14:10
member goes to another hospital, which is covered by another Blue's contract,
00:14:14
which is outside my technical network.
00:14:17
Is that what you mean?
00:14:18
You got it, not all Blues are created equal, they do compete with one
00:14:22
another, and while they are all part of the same Blue, I'm doing bunny
00:14:25
ears, program, there are fees to enter into other Blue territories.
00:14:31
That sounds great.
00:14:32
Why wouldn't I want my plan TPA, ASO, why wouldn't I want
00:14:37
them to go get me a discount?
00:14:39
Yeah, and regardless if it's just a standard out of network negotiation
00:14:43
fee that's collected, I say standard.
00:14:46
It's important for you from a feesharing perspective to understand
00:14:49
exactly what your contract says.
00:14:51
And it could be a percentage of savings over the allowed amount.
00:14:54
It could be a percentage of savings over the billed amount.
00:14:57
It really depends.
00:14:58
And sometimes the details are really, really vague.
00:15:02
Example, I read a contract not too long ago where it just said the administrator
00:15:07
reserves a right to receive a percentage of savings for any out of network service.
00:15:12
Okay, percent of savings, there's no percent there, and savings based on what?
00:15:16
Based on what reasonable and customary is, based on the allowed amount?
00:15:21
So there's no detail.
00:15:22
Request it.
00:15:23
I've also seen as high as 50 percent of savings fees for these claims.
00:15:28
You start thinking about it to your exact point.
00:15:31
First of all, what's the price that was charged?
00:15:34
The chargemaster rate, which is generally speaking this rate that, you
00:15:38
know, even hospitals always say their excuse in a way or rationale for having
00:15:42
a really high chargemaster is like, oh, no one actually pays that rate.
00:15:47
Okay.
00:15:47
So they're using a chargemaster rate to determine what the top-line price is.
00:15:53
And then the bottom-line price, I guess, is the in network, right?
00:15:56
But anyway, you can see that you'd have this huge potential savings.
00:16:02
And then if someone's taking 50 percent of that, I could see that,
00:16:05
that would add up to a lot of money.
00:16:07
A ton in certain instances, and maybe it's a small percentage of your overall spend,
00:16:11
but those fees, depending on how large of a claim it is, can be quite egregious
00:16:16
if there's no cap on what they're taking.
00:16:19
So, it's kind of absurd, really.
00:16:21
I mean, changing the rate from bill charges to usual customary or some
00:16:25
RBP method of repricing shouldn't cost 20 to 30 percent of the difference.
00:16:30
Ultimately, it would be nice to see it as a fee for service, but
00:16:34
keeping in mind most administrators year after year, they're in a
00:16:38
battle to keep their fixed fees low.
00:16:41
That's just the nature of how they're built and how the
00:16:44
marketplace is positioning.
00:16:46
So what I'm understanding you say is that there's a fierce competition
00:16:49
amongst advisors, TPAs, like this just this whole cohort and plan sponsors
00:16:54
are shopping based on fixed fees.
00:16:56
So if somebody has a cheaper fixed fee, they're like, oh,
00:16:58
I want to go with that one.
00:16:59
And then it's like squeezing a balloon.
00:17:01
It is, it is, and I gotta give props to Cora Opsahl.
00:17:04
I know she's been on your podcast a number of times.
00:17:07
She made this very brilliant statement.
00:17:10
Rates are important, but so are your rights, and your rights to be
00:17:13
able to understand what's going on.
00:17:16
So let's look at a, you know, another fee, overpayment recovery.
00:17:19
We overpay a provider, and it's out mistake is the administrator, and now
00:17:25
we're gonna collect a fee for recoupment?
00:17:28
That boggles my mind.
00:17:30
We're, we're gonna fix a mistake we made and then keep a
00:17:32
portion of that for ourselves.
00:17:35
So, they're almost always reported as claims cost.
00:17:39
But very clearly they're compensation, right?
00:17:42
That's another revenue source for the administrator.
00:17:45
So within this shared savings category, we may have also mixed up in here.
00:17:51
As you just said, TPA makes an error and then they're like, oh, I made a mistake.
00:17:57
They go and correct their mistake.
00:18:00
Get the money back that they overpaid and then charge the plan sponsor
00:18:05
to correct their own mistake.
00:18:07
It's called an overpayment recoupment fee.
00:18:09
Now, there's a lot of rumors around the industry, and we'll
00:18:12
talk about some of those.
00:18:13
You have to separate fact from fiction.
00:18:15
But it's rumored that there are algorithms in the old COBOL processing
00:18:20
for the adjudication software that every so often it'll purposely
00:18:24
overpay to collect a fee back.
00:18:26
That could be just completely malarkey, but ultimately it's one of those other
00:18:31
areas that there are fees being collected.
00:18:34
But I could see why rumors such as this begin, because if I'm a TPA and
00:18:41
I am just trying to figure out how to make more money, my incentive is very
00:18:45
perverse and it's to make mistakes.
00:18:48
Like, I get paid more if I make a mistake than if I don't.
00:18:50
Isn't that an awesome job to have?
00:18:52
Like, you get paid more for making more mistakes.
00:18:55
Alright, so in our shared savings category here, we've got the getting money back
00:19:00
if one of my members goes out of network.
00:19:03
The other bit of this also could be if I make a mistake as a
00:19:07
TPA, correcting my own mistake.
00:19:10
Is there anything else that you would lump into the shared savings?
00:19:14
I think those are really the big ones, correcting out of network, you know,
00:19:17
different BlueCard access fees, fees on the backs of the administrator themselves.
00:19:22
I think one of the big points that you're making is that these tend to be
00:19:25
invisible, as are all of these categories.
00:19:28
In other words, I don't know that.
00:19:31
Lots of my members are going to this one particular hospital that
00:19:35
is charging some rate that my TPA is then going and negotiating down.
00:19:42
Like, I don't have any of this information.
00:19:44
As you said at the top of this conversation, I'm just getting one number.
00:19:47
It's called medical claims.
00:19:48
So, if you don't know something...
00:19:51
Well, and it's the cost of doing business.
00:19:54
They'll say they have various methodologies and ways our job is
00:19:59
to understand what those ways are and make sure that we're holding the
00:20:03
administrators accountable to provide fair fees for what we're, what we're buying.
00:20:08
The problem is it's so opaque.
00:20:10
It's tough for any plan sponsor to be able to approach the market and understand
00:20:14
truly what's going on within the data.
00:20:17
And it's an uphill battle and I've, I've fought it time and time again, sometimes
00:20:20
winning more often than not we lose, but we lose getting more information.
00:20:25
than what we started with.
00:20:27
So to me, that's winning the battle to eventually win the war.
00:20:30
Which I think is maybe inspiring for those who are listening, who are getting
00:20:35
claims wires with like one or two numbers who have been fighting the good fight
00:20:39
and not winning relative to like what they're paying for on a weekly basis.
00:20:43
Stacey, those that set up auto pay for the weekly claims run and don't even
00:20:49
review them before the invoice is paid.
00:20:51
Ouch.
00:20:52
All right.
00:20:53
So the first charge that may get folded into this claims wire, we just
00:20:59
discussed these shared savings fees.
00:21:01
The second one that you had mentioned is prior auth fees.
00:21:03
What's going on there?
00:21:04
Paying fees for prior authorization.
00:21:07
It just makes me scratch my head because you as an administrator have a
00:21:12
responsibility to administer the plan the way the plan documents have been written.
00:21:17
You're essentially, are you charging a fee for doing your job?
00:21:21
That's the question.
00:21:22
Yeah, so much to unpack here.
00:21:26
So the second thing that might be buried in this claims wire
00:21:29
are these prior auth fees.
00:21:31
And I do feel like it's really important and you said this to mention
00:21:37
that on its face, ensuring that care is appropriate and evidence based.
00:21:44
That feels like something that actually could benefit a plan member to understand
00:21:48
that, wow, there's a genetic test that could determine if this drug with terrible
00:21:52
side effects that's really expensive is going to actually work for you or not.
00:21:56
And you didn't get that genetic test.
00:21:58
There's certain things which definitely could be seen as a
00:22:01
member, a win win across the board.
00:22:04
On the other hand, we have what's going on now with prior auths, which is not that.
00:22:10
And if the plan sponsors are reimbursing a payer to be doing prior auth paperwork,
00:22:16
then what incentive really does the, I mean, let's make it as complicated as
00:22:20
possible because I'm making money here.
00:22:22
Once again, it's additional compensation that probably isn't being
00:22:25
broken out on a line itemization.
00:22:27
Especially if you're really compliant with the CAA rules, asking for a
00:22:31
408(b)(2) Fee Disclosure of all direct, indirect, and non-monetary compensation.
00:22:37
Good luck getting that identified as indirect compensation
00:22:40
that was earned on the plan.
00:22:41
Yeah, and Al Lewis has talked about this quite a bit also, about actually MRI prior
00:22:47
auths, and what they basically found is that, The MRIs tended to be done anyway,
00:22:52
just in the next quarter or something.
00:22:55
So like you had all of this paperwork that was being done, such that
00:22:59
the plan could basically say, oh, I prevented however many MRIs and
00:23:03
look how much money you saved plan.
00:23:05
But then those same MRIs transpired like the next quarter.
00:23:07
So it actually was just additional, it's a profit center.
00:23:11
You hit the nail on the head.
00:23:12
So that's the second thing that, that could be included in the claims wire
00:23:16
that people should certainly be aware of.
00:23:18
And I just want to be fair to your exact point.
00:23:20
You said this, there is value here if it's done in a way that's a win win with
00:23:26
the plan sponsor and if those dollars are transparent, but the way it's
00:23:30
currently being done may not be a win win and it's very, very not transparent.
00:23:34
I would agree.
00:23:35
Uh, okay.
00:23:35
So the third thing, prepayment integrity, I think you said.
00:23:39
Yeah, so evaluation of the claim itself before it's paid.
00:23:47
So a lot of folks will say, well, is that different than what the TPA is doing?
00:23:53
The fact of the matter is the TPA in most instances, 85 percent of
00:23:57
the claims are auto adjudicated.
00:23:59
So how much review is going into that live weekly run of claims?
00:24:04
I would argue it differs from administrator to administrator.
00:24:08
I would be concerned on how high the auto adjudication rate is for a lot
00:24:13
of these vendors that are out there.
00:24:15
I would prefer to have better oversight at time of claim processing.
00:24:21
So, what does that look like?
00:24:24
Right now, I would say that there's not enough of this going on.
00:24:28
Technically, under the ERISA guidelines, to be prudent, loyal to the plan, you
00:24:32
have to understand what's going on within the claims themselves and also have
00:24:36
to understand to some level of detail exactly what it is that we're paying for.
00:24:41
So in this you might see things like upcoding, unbundling, a number of
00:24:45
issues that we'll talk about in the pay and chase model, but here we have
00:24:49
a great opportunity with technology and artificial intelligence to implement
00:24:54
a better, a better methodology of analyzing these claims at the
00:24:58
time that they're being processed.
00:25:00
As opposed to some of the archaic technology that's being used
00:25:03
with the systems that are behind the scenes at the administrator.
00:25:07
It sounds like there's two ways a plan sponsor might get charged by
00:25:11
their administrator to process claims.
00:25:14
One of them is the administrative fee, which is, that's what it's supposed to
00:25:17
be used for, right, processing claims.
00:25:20
But then there may be a second goings on, which the plan sponsor is paying
00:25:25
for in this category, this prepayment integrity, in which like they're doing
00:25:28
something else over and above just merely administering claims in order to
00:25:35
ensure that the claims paid are correct.
00:25:37
Let me, let me lay this out to you.
00:25:39
Sometimes the carrier agrees in the provider contracts not
00:25:41
to review claims prepayment.
00:25:43
So the errors are let through intentionally or unintentionally, if
00:25:46
you will, as none of the claims are reviewed in detail prior to payment.
00:25:50
Why catch it prepayment when you are compensated more to find it post-payment?
00:25:55
Yeah, so what we're talking about right now in this category, as we
00:25:59
just mentioned, is this prepayment and integrity, the administrator, what they're
00:26:04
doing is charging an over and above fee to ensure that the claims are accurate.
00:26:11
And this could be happening prior to the claim being paid, but it
00:26:14
would be considered not normal.
00:26:16
Right.
00:26:17
So like maybe some are being, you get flagged for some reason and stuck
00:26:21
down the second shoot and looked at more carefully is that what do they
00:26:26
even explain that they're doing?
00:26:27
It's very prudent if your administrator's not doing a good job on the front end,
00:26:33
it really pays dividends to ensure that you have some sort of vendor in
00:26:39
there that's aggressively demanding this information and requiring it
00:26:43
to be shared as set forth in the gag clause prohibitions under ERISA.
00:26:48
This is one of the, one of the five that I think it's okay to pay
00:26:51
more money for because it's needed.
00:26:53
Accuracy is needed earlier on in the adjudication process.
00:26:57
There's point solutions that have developed out there that allow for
00:27:01
increased oversight and understanding of what is happening with the
00:27:05
claim before it actually gets paid.
00:27:08
You're not going to see that in most administrators because they're
00:27:12
incentivized to have errors with some of these other fees that we talked about.
00:27:17
In most instances, the really good administrators out there tend to
00:27:22
lose a lot of business because if they're doing a better job on the
00:27:25
front end, they tend to cost more.
00:27:27
And this is just because of the whole squeezing the balloon thing.
00:27:30
If they're up front, there's just enough employers who don't really
00:27:34
understand that you're going to pay for it on the front end.
00:27:37
And if you don't pay for it on the front end, you're going
00:27:39
to pay a lot on the back end.
00:27:41
So much on the back end.
00:27:43
I'll use a good example.
00:27:44
We got a fund that's a multi-employer fund.
00:27:46
It was spending about $13 million annually Just by virtue of doing
00:27:51
a better job on the front end, we reduce that expense by $1.5 million.
00:27:56
Wow.
00:27:57
I think it's becoming very clear to me just how much money is, is being
00:28:01
spent on that wire that doesn't, again, accrue to member health or
00:28:06
may not be a spend that has value.
00:28:09
If I'm going to put it that way.
00:28:10
This is much like the ShamWow guy.
00:28:13
Oh wait, there's more.
00:28:14
We can, if you want to, get into pay and chase.
00:28:16
Yeah.
00:28:17
Let's talk about pay and chase.
00:28:18
So this is our fourth category.
00:28:20
We've talked about shared savings.
00:28:22
We've talked about prior auth fees.
00:28:23
We've talked about prepayment integrity.
00:28:26
This is number fourth, pay and chase.
00:28:28
Pay and chase is not getting paid a shared savings fee if a patient goes
00:28:34
out of network and the administrator can negotiate some discount.
00:28:38
We already talked about that.
00:28:39
This is also not getting back dollars that the administrator paid by mistake
00:28:44
and then fix their own mistake.
00:28:46
That's also something else.
00:28:49
Pay and chase.
00:28:50
There was dollars that were paid, which were deemed to be wrong.
00:28:52
So maybe it was the provider overcharged.
00:28:55
That's most of what's in this category.
00:28:57
And I, as the administrator, have realized that the provider sent
00:29:01
me a wrong bill that got paid.
00:29:02
So now I'm going to go chase after those dollars and get them back.
00:29:06
Did I get that right?
00:29:07
Correct, and maybe within the claims there's unbundling, there's
00:29:11
upcoding, maybe there are a number of issues, uh, that you find in
00:29:15
when you're comparing some of those claims to case management notes and
00:29:19
let me, let me add an asterisk here.
00:29:21
Sometimes you're only looking at large claims, right?
00:29:23
So there are literally like thousands and thousands of claims that would fly under
00:29:28
the radar that may not get audited, that could have errors, that could add up.
00:29:32
It's just, it's, you have to be prudent.
00:29:34
Julie Selesnick was on this show a couple of weeks ago, and she's like, it is the
00:29:40
very definition of a fiduciary breach.
00:29:42
When you have the one auditing your claims, also the one who's doing the
00:29:47
claims, like, that is not prudent from a fiduciary standpoint, by any definition.
00:29:53
She is so right.
00:29:55
You look at like the J&J lawsuit, that's a big consideration for everybody regarding
00:30:00
what they're doing within their plans.
00:30:03
I had another Taft Hartley fund, wanted to do an audit.
00:30:07
They used the approved vendor to audit their claims.
00:30:10
The one that was approved by the network.
00:30:12
Lo and behold, the auditor found around $21.
00:30:17
in errors that they got money back from the administrator.
00:30:22
Can you take a guess what the fee was for that audit?
00:30:25
$21 was overpaid vis a vis errors.
00:30:29
And you're asking me what the fee the auditor charged to find that 21k was.
00:30:35
Correct.
00:30:35
It's $25.
00:30:37
Like, like, so you didn't even, you didn't even recoup enough money to
00:30:42
pay your own fee, which is ridiculous.
00:30:44
This is on millions and millions of dollars of claims.
00:30:48
So, we finally get the ability to do an audit with an independent party, right?
00:30:53
Somebody that we brought in.
00:30:56
Same amount of claims, same issues.
00:30:58
And they come out with more than 20 times that in errors?
00:31:04
Come on, man.
00:31:05
Are you kidding me?
00:31:06
Yeah.
00:31:06
Well, I mean, you got the fox guard in the hen house.
00:31:10
I mean, honestly, like you're going to hire the same exact company that's
00:31:14
doing the work to audit their own work.
00:31:16
In what world is that a good idea?
00:31:19
I talked to a plan not too long ago that has a couple
00:31:20
hundred million in annual spend.
00:31:23
And I asked, like, who's advising you?
00:31:25
And they're like, my administrators, also my network,
00:31:29
which also is also my stop loss.
00:31:32
We also use their PBM and then our actuary and advisor is also a part of their team.
00:31:37
I don't mean to laugh.
00:31:38
I'm sure it's very efficient.
00:31:40
I guess efficient to waste hundreds of millions of dollars.
00:31:43
That really segues into the TPA themselves and the TPAs and the
00:31:48
claim review that they're doing.
00:31:49
That would be the the fifth part.
00:31:51
Okay, so right now we have segued, as you said, into number five,
00:31:57
which is our TPA claim review.
00:31:59
What's, what's this?
00:32:00
Yeah, so this is just your basic administrator.
00:32:02
I mean, most administrators, and I'll quote a dear friend of mine,
00:32:06
Mark Davenport, he said, TPAs are kind of like khaki pants.
00:32:10
They're all pretty much the same, just a different shade of brown.
00:32:14
And he's right, all the claims have a network relationship.
00:32:18
Most of them are beholden to the network relationship, meaning that they're gonna
00:32:21
follow whatever the network rules are regarding what they're allowed to do with
00:32:25
the claims that they're adjudicating.
00:32:27
Most of these administrators, as I said, are auto adjudicating claims.
00:32:32
85, 90 percent of claims that flow from the provider have to
00:32:36
visit auto adjudicated, handled by software, not by people.
00:32:41
The auto adjudication process, checks for eligibility, prior auths, coverage,
00:32:44
plan design, member liability.
00:32:46
The problem is, is how accurate is that information that's just
00:32:50
hitting the software and paying?
00:32:51
It's a good question.
00:32:52
It is a good question.
00:32:53
Not many people know the answer to that question or are willing to
00:32:56
delve in to understand that with each of the administrators that they're
00:32:59
reviewing and potentially hiring.
00:33:01
You had alluded to when we were talking about our number three category,
00:33:04
which is the prepay integrity, that it's worth it to pay somebody.
00:33:08
Third party to do some due diligence here, TPAs are, you know, that's what
00:33:14
your administrative fee goes to paying to have these claims adjudicated,
00:33:18
but they may be doing a great job or they may be doing a really, really
00:33:22
bad job and you would never know it unless you have third party experts
00:33:28
with their eyes on what's going on.
00:33:32
100%.
00:33:33
Here's a great quote from Karen Handorf that she said to me the other day.
00:33:36
She said, getting gag clauses out of your contracts is a useless exercise
00:33:40
if you don't look at the data to figure out how it is hurting, not just you, the
00:33:45
plan, but the plan participants as well.
00:33:47
You hire an administrator.
00:33:49
They tell you they're going to do a great job.
00:33:51
Some of them might say, oh, we have a really, really high out adjudication rate
00:33:55
and we pay claims accurately and timely.
00:33:59
What does that really mean?
00:34:00
Okay, you're paying them accurately in timing.
00:34:02
How do you define that?
00:34:03
How do you define a clean claim?
00:34:05
How do you define the, the access rights that I have to be able
00:34:09
to review claims, whether it's a $20 claim or a $2 million claim.
00:34:14
And this is exactly also what any number of guests on this show have said.
00:34:19
Julie Selesnick, Dawn Cornelis was on the show.
00:34:22
You mentioned Dawn.
00:34:23
It's not only getting the data, but it's also using it.
00:34:27
A hundred percent.
00:34:28
You have to use it.
00:34:29
Data's data, so what?
00:34:31
What are you going to do with it?
00:34:32
You know, there's that Jim Collins quote, you can't manage what you can't measure.
00:34:36
And the data enables measurement.
00:34:39
It's a marketing statement to say that I, if I'm a TPA, the front page
00:34:44
of my website, it's going to be all about how amazing I am at adjudicating
00:34:47
claims, but it's a marketing statement.
00:34:49
It is.
00:34:49
You got to get the data to check.
00:34:51
There are dozens of TPAs out there that are involved with fully-funded,
00:34:56
level-funded, self-funded, they're involved with captains,
00:34:58
they're involved with consortiums.
00:35:00
Complacency is not okay.
00:35:02
It's now against the law.
00:35:04
I think people walk in with their sorcery.
00:35:07
I have this magic box of smoke and mirrors, and I will just feed
00:35:12
your claims in the one side, and I will get you 10 percent savings.
00:35:16
You know, like we had A.
00:35:17
J.
00:35:17
Loiacono on the show, and he said he was talking to some
00:35:21
broker and the broker said, A.
00:35:23
J., I can make the spreadsheet show anything I want.
00:35:26
And I think that's what we're talking about here.
00:35:28
One of A.
00:35:29
J.
00:35:29
's folks, Mike Miele, we talk about that all the time.
00:35:32
He'll be on that spreadsheet or we'll be having that discussion where somebody just
00:35:35
comes in and buys the business or shadow prices the, the lowest possible number.
00:35:41
And it's like, what are you buying?
00:35:42
You could save $100 on the front end, on the back end,
00:35:45
it's going to cost you millions.
00:35:47
Another thing that I have heard sometimes gets charged for within this claims
00:35:51
wire in the process of paying for claims is spread pricing and medical claims.
00:35:57
And I've certainly, I'm sure everybody who listens has heard this relative
00:36:01
to pharmacy claims, but there's medical claim spread pricing as well.
00:36:05
We certainly think it exists.
00:36:07
It's hard to say exactly where and how it's happening.
00:36:10
It's obviously, as you said, known within PBM pricing, the J&J complaint
00:36:15
discusses it in some detail.
00:36:16
It's thought that it is happening on the medical side, although we
00:36:19
don't have hard definitive proof, but we have enough evidence that
00:36:23
we think it sure is happening.
00:36:26
This is personal to me.
00:36:27
Many know that there's a complaint filed with the Bricklayers,
00:36:30
Local 1 in Connecticut, and Sheet Metal Workers against Anthem.
00:36:34
The Bricklayers are a client of ours.
00:36:36
One of the allegations is that there's money added to the actual cost of
00:36:40
a claim that either goes into the pocket of the insurer or provider,
00:36:43
which is still to the benefit of the insurer, who would otherwise be
00:36:47
on the hook for the compensation if it's being paid to said provider.
00:36:51
Yeah.
00:36:51
So just understanding what a spread is, is that the plan sponsor is
00:36:57
being charged a hundred bucks for some claim, but the provider is
00:37:03
only being reimbursed 50 bucks.
00:37:06
Therefore somebody in the middle, just made 50 bucks.
00:37:10
It doesn't disappear into the ethos.
00:37:12
And as we have more transparency files, machine readable files that are
00:37:16
made available, where we can look at specific procedures, services, and then
00:37:20
compare what the publicly posted price is for negotiated rates, we can start
00:37:26
to ask some very poignant questions.
00:37:28
But even look at the DOL case against Blue Cross Blue Shield of Minnesota.
00:37:32
It involves spread pricing if the provider agreement says it is the
00:37:36
obligation of Blue Cross Blue Shield to pay the shifted provider tax.
00:37:40
It's a hidden fee that gets pulled in.
00:37:42
So that's the whole basis of the lawsuit.
00:37:44
So does it exist?
00:37:45
I would argue, yes.
00:37:47
Interesting.
00:37:48
So basically what you're saying is that there, there are indications to show
00:37:53
that what the providers are charging for any particular claim might be less than
00:37:58
what the plan sponsor is getting charged.
00:38:00
Therefore there's dollars in the middle, which is often referred to as the spread
00:38:03
and relative to this DOL, Department of Labor case against BCBS Michigan, I think.
00:38:09
What was going on there is that the plan sponsors were unbeknownst to them paying
00:38:14
taxes on behalf of providers, right?
00:38:16
So the providers have to pay taxes, and it turned out plan sponsors
00:38:19
were paying provider taxes.
00:38:21
And to your point, you're like, how are they paying providers taxes?
00:38:25
If there wasn't dollars in the middle there, which were being added to
00:38:29
claims that the plan sponsors were told, oh, you're paying claims.
00:38:33
You got it.
00:38:34
See, listen, it doesn't take a rocket scientist.
00:38:37
It just takes a little bit of sleuthing to connect the dots and understand that this
00:38:40
is just another form of spread pricing.
00:38:42
Justin Leader, is there any place where you would recommend people
00:38:47
go to learn more about your work?
00:38:50
I put a lot of information out there on LinkedIn.
00:38:52
So look for me on LinkedIn, Justin Leader, the one out of Pennsylvania,
00:38:57
not the one out of California.
00:38:58
You can also go to benefitsdna.com or wefixyourhealthcare.com.
00:39:03
And I would highly recommend following Justin on LinkedIn.
00:39:07
We will link to Justin on LinkedIn as well as the two
00:39:11
websites that he just mentioned.
00:39:13
Justin Leader, thank you so much for being on Relentless Health Value today.
00:39:16
Thank you, Stacey.
00:39:17
I'm a big fan of your podcast as I've shared time and time
00:39:21
again, I'm a bit of a fan boy, so it's an honor to be here today.
00:39:24
So let's talk about going over to our website and typing your email address
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00:39:32
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00:39:36
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00:39:40
What you get in that email is a full and unredacted, unedited version of the whole
00:39:47
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00:39:49
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00:39:55
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00:39:57
Thanks so much for listening.