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Moving from Transparency to Control: BenefitsDNA Elevated Insights 2026
Last Thursday I was in Harrisburg, Pennsylvania for the BenefitsDNA Elevated Insights Summit. The theme was "Moving from Transparency to Control," and if you spend any time in healthcare benefits, you know there is a lot of distance between those two words.
It was a single-day event held in Harrisburg, Pennsylvania. The audience was mostly HR leaders, CFOs, and benefits professionals from employers of various sizes across the region. The format mixed keynote presentations with practitioner case studies and a live roundtable. Below are some insights and thoughts.
Employers Architecting Their Own Health System
Lee Lewis, Chief Strategy Officer and GM of Medical Solutions at the Health Transformation Alliance (HTA), opened the day with a roadmap for employers who have accepted that no one is coming to rescue them.
HTA traces its origin to 2015, when a small group of CHROs from IBM, American Express, Verizon, and Caterpillar Inc. sat down and compared notes. They were outperforming in compensation, recruiting, talent development, and retirement. Healthcare was the exception. Costs were out of control, and they had no meaningful levers. They built a nonprofit co-op to share what was working. That group has since grown to around 80 to 85 large employers.
His goal for the session was to share what is working across HTA members so the room could take it and apply it. He offered a concrete example early: one employer was tracking a projected +9% trend, implemented an aggressive plan management approach, and landed at -14% instead, a 23-point swing that saved them over $30 million.
Lee organized his medical strategy around three pillars: Data, Dollars, and Design.
Data. The starting point is getting your claims data out of your carrier or TPA and into a place you control, either an independent data warehouse or a server you own. Benefits teams spend at least three months of every year just moving data from system to system. The goal is to end up with basic KPIs you can read: gross per-member-per-month spend, trend month by month, and category-level views where savings are known to exist.
Dollars. Once you have the data, the question is how much you are overpaying and where. Most carrier contracts include audit provisions, and a good audit firm typically works on contingency, costing little to nothing after recoveries. Lee broke billing abuse, waste, and errors into three buckets with memorable names:
White-collar: Playing with the mechanics and the numbers to extract more value. This includes upcoding, bundling and unbundling codes, duplicate code submissions, and eligibility games. Lee’s shorthand for it was white-collar abuse: not a billing error, but a deliberate manipulation of the system.
Grand Theft Auto: Claims over $100,000, low in volume but high in risk. Lee compared these to large congressional spending bills: dozens of pages long, packed with hundreds of line items, and rarely scrutinized closely. That creates an opening for extra charges to get thrown in, $100 toothbrushes, additional implants, line items that have nothing to do with the actual care delivered. The size of the bill is what provides the cover.
Shoplifting: The candy bars that vanish from the store, the packs of gum that disappear from the countertop. In healthcare billing, this is lots of small charges thrown onto otherwise already small claims: an extra lab here, a small add-on there. Each one is low enough that nobody pays attention to it, and so it gets ignored. The volume is what makes it dangerous.
The shoplifting examples were specific. A chain of private equity-owned clinics in the Southeast was adding a $94 test bundle to every patient visit regardless of age, sex, or clinical presentation. Nobody flagged it because it was $94. For one employer, that added up to $1.8 million. A separate story was shared involving a phantom provider in El Paso was billing approximately $1 million per year per employer while showing as permanently closed on Google Maps. His recommended diagnostic: export your provider list to a spreadsheet, sort by geography, and look for addresses outside your employee footprint. It does not require sophisticated analytics. It requires having your own data.
Design. Lee was explicit about what he does not spend time on. Co-pays and deductibles are behind glass, only to be broken if necessary. His focus is structural policies.
One he highlighted is the Medicare Secondary Payer Act, a piece of legislation that began forming in 1978. For patients with End Stage Renal Disease (ESRD), the law creates a coordination period during which the employer plan remains primary and Medicare is secondary, regardless of whether the employee is still actively working. The structure works like this: there is a three-month window at the start with no Medicare coverage, followed by 30 months during which Medicare is secondary to the employer plan, and then at month 33 Medicare becomes primary automatically, even if the employee still has employer-sponsored coverage.
Here is where it gets interesting. Providers who treat Medicare beneficiaries are bound by Medicare's rules on what they can charge, even when Medicare is secondary. That means the Medicare allowed amount is effectively a ceiling on what the provider can bill the patient, regardless of which plan is paying first. During the 30-month coordination period, the employer plan pays its contracted rate, which is almost always at or above the Medicare allowed amount. Once that threshold is met, there is nothing left to balance bill. The patient is fully protected whether the employer plan realizes it or not.
Most employers never act on this. They keep paying four, five, or six times the Medicare allowed amount throughout the entire 30-month window, covering a protection that was already guaranteed by Medicare's rules. Then at month 33, when Medicare should flip to primary and the employer plan should step back, most plans keep paying as if nothing changed. Lee described it as roughly equivalent to voluntarily overpaying your taxes in a category where Congress has already told you that you do not have to. His message to the room: this law has been sitting there since 1978, and most employers are not using it.
He also shared a data point with the audience about out-of-network billing. HTA ran an analysis on claims data and found that only a small percentage of doctors list a PO box as their only address. Unusual on its own, but when they compared those doctors to doctors who were also out of network, there was a 90 percent overlap. That is not a coincidence. A significant share of what he called true out-of-network billing, not the emergency room or the anesthesiologist, but discretionary out-of-network, is where a disproportionate amount of the billing abuse and excess fees concentrate. Several HTA employers have dropped out-of-network coverage entirely and braced for complaints. Almost none came.
Lee told employers to create a second, richer in-network tier even if there is nothing in it yet. Then treat the marketplace like a thrift store: look across local providers, identify facilities with better pricing and outcomes, and pull them into the premium tier. Once you have the shopping cart, you can fill it with surgical centers of excellence, imaging networks, and any narrow high-value network you identify.
His pharmacy section introduced a five-part framework he called Clear, Steer, Severe, Adhere, Procure.
Clear. Getting to a net fixed price per drug, post-rebate. What matters is the contract and the ability to deliver, not the branding a PBM uses.
Steer. Building an employer-controlled formulary that defaults to the lowest net cost option where clinical efficacy is equal or better. One HTA employer using this approach has achieved eight consecutive years of flat pharmacy trend. Another has cut pharmacy trend in half.
Severe. Specialty drugs. Every employer Lee has seen that has carved out specialty has saved more than $30 per employee per month. The savings stack separately on the pharmacy side and on the medical infusion side.
Adhere. Somewhere between one and two percent of people are inadvertently taking dangerous drug combinations. An adherence layer sends pharmacy data monthly to a PharmD, who scans for interactions, calls the prescribing physician, gets the regimen corrected, and follows up with the patient. The cost is roughly $75 per intervention, billed as a claim. Lee shared that most people would love to have a private conversation with a pharmacist, but not at the pharmacy counter with three people behind them in line. He described it as the service all of us need but none of us knew we wanted.
Procure. Direct drug purchasing is moving faster than most people realize. One HTA employer is now buying more than half of its drugs without using a PBM, and the percentage is increasing every month.
Lee shifted to provider strategy with important context. According to the American Medical Association, the share of physicians in private practice has been declining for decades, falling from an estimated 76 percent in the early 1980s to 42.2 percent in 2024, the lowest level on record. Hospitals and carriers have been acquiring independent practices, and many physicians who remain independent are exiting fee-for-service because the payment model creates misaligned incentives: it rewards visit volume more than patient outcomes. Direct primary care resolves this by moving to a monthly subscription model where patients can text, call, video, or come in when they need to, and the physician is compensated regardless of the encounter type. What this creates is what Lee called the primary care paradox: all the primary care doctors who take insurance are not taking new patients, and all the doctors who are taking patients are not taking insurance.
HTA worked around this by connecting direct primary care physicians with a billing arrangement where a third-party billing service handles payment on behalf of the employer, the physician gets paid in a way that works for their practice, and the large employer gets access through a structure that fits within their existing plan. By doing this, HTA has been able to open approximately 5,000 additional locations. The net promoter score across 200 different businesses runs between 83 and 89 every month. Lee's take on what that means: "It's not one business that has figured this out. The business model is working if people who've never met each other, from Miami to Anchorage to Seattle, can open up a primary care office on the same principles of just putting the patient first. Patients across the country every month are having the same great experience. This shows us that the model needs to be changed. It's not a fluke. It's not a lucky accident."
He organized the full provider strategy into three categories he called A, B, and C.
A: Advanced Primary Care. The direct primary care model described above. For employers with a local footprint, Lee suggested contracting directly with one or two area providers. For national employers, it can be activated through a carrier.
B: Behavioral Health. The DOL has found that no carrier network evaluated has been mental health parity compliant. Lee compared going without supplemental behavioral health coverage to being a pirate at sea with no lifelines: you might have everything else you need, but that gap catches up with you fast. He recommended supplementing the network with a direct contract with a local practice or one of the major virtual behavioral health vendors and said it was hard to go wrong picking one.
C: Centers of Excellence. Companies that have gone out and secured direct contracts for surgical services at a low fixed bundled rate have found them to be a best practice. Lee's suggestion was to take those contracts and drop them into the premium tier of the two-tier in-network benefit structure he described earlier: offer it, make it free or near-free for the member, and let people opt in. For many employees, he noted, a center of excellence arrangement is the only realistic way they can afford surgery at all.
He closed with an unfortunate story relative to some important work on the FDA front. Dr. Marty Makary M.D., M.P.H., a Johns Hopkins surgeon and long-time advocate for evidence-based standards, was confirmed as FDA Commissioner in March 2025. Lee described it as one of the most encouraging appointments he had seen in a long time. Recently, a series of circumstances unfolded involving regulatory decisions on products Makary had raised concerns about, and he resigned. Whatever one thinks of the specifics, Lee's point was not about politics. His point was that even the most well-intentioned individuals operating inside institutions are subject to pressures that employers cannot predict or control. "We have to be looking out for our people, because nobody is coming to do it for us."
Prioritize Payment Integrity
Michael Berry of WellRithms, Inc.™ brought 30 years of payment integrity experience to the room and framed the entire problem using his background as a volunteer firefighter.
Fire services operate on two modes: prevention and suppression. Building codes, inspections, and investigations of root causes like defective space heaters are prevention. Putting out the fire is suppression. Healthcare payment integrity has spent most of its history on suppression. The argument Mike made is that the resources need to shift left.
Mike shared error rate statistics illustrating that somewhere between 50 and 80 percent of medical bills contain at least one error, and those errors often favor the provider at the expense of patients and employers. A partial knee replacement in central Pennsylvania can vary dramatically in price depending on the facility, with no evidence that higher-cost options deliver better outcomes.
Mike named four billing patterns that come up consistently in his work:
Duplicate billing: A provider and a billing company each submit a claim for the same service
Upcoding: A three-stitch laceration comes in as a Level 5 emergency visit
Infusion, cell & gene therapy markups: In the range of 500 to 1,000 percent
Phantom billing: Billing for procedures that were canceled or never performed
His central case study involved a 21-year-old woman who broke her wrist on Halloween. She had outpatient surgery at a center owned by the hospital and went home three hours later. The bill came in at approximately $700,000. His company's medical director, a 40-plus-year orthopedic surgeon, reviewed it and said there is no physical way to insert 12 pins into an NFL player's wrist, let alone a small-framed 21-year-old. The actual procedure used two pins. The bill should have been closer to $50,000. When challenged, the surgeon's office said it was a transcription error: they meant to write "2" and were not sure how the "1" got in front of it. The carrier's claims system had processed the $700,000 bill without flagging it. When Mike's firm surfaced the error, the carrier ran it through their shared savings program, corrected the bill, and charged their client 45 percent of the savings they identified. They charged to fix their own mistake.
Mike described a structural conflict that applies broadly: when the same organization that processes and pays your claims also runs the payment integrity review and charges you to find errors in bills it approved, you are looking at a governance problem, not just a vendor issue. "When the same people doing the work are the only ones doing the review, you really have to think through that."
Mike shared his thoughts on AI, noting that roughly 85 to 90 percent of claims can be handled by machines. The remaining 10 to 15 percent, which tend to be the highest-dollar and highest-risk claims, require physician-level judgment. His company uses physician review on those cases specifically and has an under-one-percent pushback rate from providers, which he attributes to explaining the clinical reasoning behind each decision rather than simply reducing a number on a bill.
He had a practical call to action: even if you cannot win prepayment review from your carrier, you can demand the data, look for outliers in a spreadsheet, and document what you asked for and what you were told. If you are ever audited, the question will not be whether you were perfect. It will be whether you had a process. "The fiduciary duty can't be shied away from. You can't give that away to somebody."
"Here's What Happened When We Made the Switch to Self-Funding"
Nathan Erway, MBA is the CFO of Verber Dental Group, a locally owned dental health system with 12 locations in Central Pennsylvania. His talk was deliberately framed as non-MBA, non-sales, peer-to-peer: "Here is what happened when we made the switch to self-funding, and here is what actually surprised me."
His description of the fully insured renewal cycle was relatable to anyone who has been on the employer side of that conversation. The broker calls three weeks before the decision deadline with a 30 percent increase. You push back. They negotiate and return with 22 percent. You have a week to decide. There is no claims data, no visibility, no leverage. He used the phrase "rock on my head" to describe what that felt like year after year.
The question he brought to BenefitsDNA was simple: is there a different way to think about this? He was practical about his skepticism. When Justin told him the switch would not cost him more than what he was already paying, he remembers thinking: do I trust this guy? He did the work: licensed and regulated, financially sound, track record, ability to show real data, qualified team. The answers came back yes. He signed on.
In the first full year of self-funding, Verber saw a 17.32 percent reduction in premium cost. The next renewal came in at negative 1.7 percent, down from an initial offer of a 3.9 percent increase. He negotiated using claims data he now had access to and had never seen before. He described what it felt like to finally have visibility into the detail: years of spending with no idea what was driving it, and now the ability to see it all.
Beyond cost, there is a customization story. Most Verber employees are female. They built a nurse advocate program into the plan design: if a pregnant employee meets with a nurse advocate before 26 weeks, up until they give birth, they receive free diapers for a year. Nate described the reaction in the room when people first hear about it. The benefit gets more engagement than anything else in the plan because it is specific to their actual population. He calls it a hidden benefit, something people do not realize they have until someone in HR tells them.
Nate said he would take the leap to work with BenefitsDNA again without hesitation. The moment that confirmed it for him was receiving a renewal decrease for the first time, after years of dreading that call every year. He acknowledged that no plan year is perfectly predictable, but his point was not a warning about volatility. It was that self-funding, done right, gives you the tools and the data to consistently bend the curve. The alternative, he said, is staying fully insured and watching the increases come year after year. "It just keeps going in that direction."
"Don't Get Sued" Live
This session was hosted by Justin Leader, CEO and founder of BenefitsDNA, and featured Julie Selesnick, an ERISA attorney who spent 20 years in litigation before concluding that the better move is to fix the contract before signing it, alongside Shawn Gremminger, President of the National Alliance of Healthcare Purchaser Coalitions, representing over 90 million covered Americans and roughly $850 billion in annual spend.
The session used skits to illustrate what is happening in employer health benefits. One involved a retail store that overcharges you by $100, acknowledges the error, and then keeps 40 percent of the refund as an administrative excellence fee. Another involved a fitness tracker company that ingests your health data, declares it a trade secret because of how it processed the data, and offers to sell you back your own wellness insights in an annual report. A third showed a sweater that costs $280, comes with $150 in store credit delayed by a quarter, and includes undisclosed payments from the manufacturer to the store that never make it to you. These are not abstract analogies. Each one maps directly to a specific mechanism: shared savings recovery programs, carrier data gatekeeping, and PBM rebate structures.
Shawn described where employers sit on what he called a bell curve of awareness and action. A leading edge of employers has already dumped legacy contracts, moved to direct contracting, and started challenging conflicted advisors. A large middle is becoming aware of what the Consolidated Appropriations Act and gag clause attestations require but is not yet sure how to push back. A significant segment still has no idea that the legislative and market landscape has changed significantly over the past six years.
Shawn's top three employer cost concerns:
Hospital prices. Should be the number one concern, even above pharmacy, because that is where most of the money is going.
Pharmacy spend. A legitimate second priority, and one that is getting significant attention from policymakers on both sides of the aisle.
Access to claims data. The inability of employers to see and use their own data sits underneath both above. Without it, neither problem can be addressed effectively.
"The last one is opacity, lack of transparency, access to data. That correlates very directly to the inability of employers to see their own data, use their own data, compare it to publicly available sources, and actually do something."
Julie's framework for contract strategy is upstream. The leverage is at the RFP stage, before you sign. Her specific advice on data: stop trying to scrub every gag clause out of your existing contracts and focus instead on hard-wiring data rights in new ones. Define the layout you need. Specify weekly or monthly feeds. Lock in electronic transfer protocols. Negotiate a confidentiality agreement that gives your vendors the same access your counterparties want for themselves. And put a data supremacy clause at the top: regardless of what else this contract says, here is how the data is going to work.
On the fiduciary duty front, her message was practical: regulators and courts are not looking for perfection, they are looking for a documented process. Did you ask questions? Did you follow up? Did you push back when the answers were unsatisfactory? If a carrier says they do not have to give you your claims data, document that you asked, document what you were told, and keep asking.
Shawn noted that the DOL proposed a PBM fee disclosure rule in January 2026, with a public comment period that closed in April. The rule is still pending finalization, but once it takes effect, entering into a PBM contract without the required disclosures will constitute a prohibited transaction under ERISA. Julie's advice was to hold the line on this even if it creates friction. "Stand on that hill. It's worth it."
"The Bottom Doesn't Scare Me. Staying There Does."
Nicholas Ade is the executive director of Central Pennsylvania Youth Ballet (CPYB), one of the four foremost ballet training schools in the country. He shared an incredibly personal story that helped put the importance of care into perspective for everyone in the room.
He opened with Timothée Chalamet's comment that no one cares about ballet or opera anymore. He did not push back. He said Chalamet is not wrong. He has spent almost his entire life in ballet, and he acknowledged the parallel directly: people outside the benefits industry feel the same way about health insurance. Too complicated. Too chaotic. Too many acronyms. Some of them see brokers and HR professionals as part of the problem.
His background is not one of natural ease. His father was a successful VP of Underwriting at Transamerica who went independent as a stockbroker three months before Black Monday in 1987. The financial collapse brought severe depression into the household. As a 12-year-old, Nick started helping his mother with the checkbook and the bills. The key insight he took from watching his father during that period was not about money. It was that his father wanted the world to stop for him, and it did not. He never forgave it for that. Nick formed a different orientation early: "The bottom doesn't scare me. Staying there, that's what scared me."
Ballet became his structure, not his passion. No weekends. No off-season. No MVPs or championships. The only reward for showing up and doing the work is being allowed to come back tomorrow and continue. He described it as a relentless pursuit of perfection with full knowledge that perfection is not attainable.
At 18, accepted to San Francisco Ballet School, his first class ended with his idol telling him that he did not belong there. He went back to his dorm room, recognized he had two choices, and chose the harder one. He worked construction from early morning until noon, trained at the ballet school from noon to 4:30, and bused tables at a fine dining restaurant on weeknights and weekends. Every week, week after week.
On Saturdays, he and one other student showed up for class with Ricardo Bustamante while the other students skipped. Ricardo was furious. He gave those two students the hardest class Nick had ever been through. This repeated every Saturday. "He's trying to shove a week's worth of improvement into my body because he's pissed at everybody else who's skipping." By the end of his second year, Nick had won the most prestigious scholarship the school offers. From being the one they did not know what to do with to being the example they pointed to.
He was later told at a professional company that he did not have a body for classical ballet and would have a ceiling there. He spent two years changing as much as he could about the structure and shape of his muscles through stretching, cross-training, massage, and dietary changes. Two years later, a senior dancer told him: "What the hell did you do? You look like a dancer now." He went on to a 10-year professional career. His line about all of this: "Last year's work is never going to be the same or enough as the work that needs to be done today. You have to adapt. You have to change. You never arrive."
He had a stroke while leading CPYB. His daughter, around nine years old at the time, stood in the doorway of his hospital room. He recognized the fear on her face immediately because he had worn it himself as a child watching his father. He called her over, sat up, took her hand, and told her he was going to be fine. He was not sure whether he was trying to convince her or himself, but he knew she needed to hear it, and he knew it was something he had never heard. He later survived a bladder cancer diagnosis. The night before surgery, he went to a dark place, and he described it as being entirely about other people: what do the holidays look like without him, does his daughter want risotto at Thanksgiving because that is the dish she always says is better than anywhere else, who walks her down the aisle. He allowed himself to go there. He came back. And from that point on, each day looks different to him.
His charge to the room was direct. You have spent today collecting information, hearing stories, and thinking about strategy. Now you have a responsibility to do something with it. The people you serve do not understand PBMs and MRFs and all of it, but you do. "Get up and help educate, help make a difference in your decisions so that other people have better lives." Someone is watching how you respond to the problems in front of you. Make sure they see you get up.
State-Level Developments
A speaker roundtable at the end of the day covered state-level developments. California has required hospitals to publicly disclose their chargemasters since 2004. Indiana mandates that large nonprofit hospital systems offer direct-to-employer contracts capped at 260 percent of Medicare, with the requirement in effect as of September 2025. Vermont has directed its Green Mountain Care Board to implement reference-based pricing for hospital services, with initial implementation focused on state and public employee health plans, where hospital payments have been averaging close to three times Medicare for comparable services. Even where federal action is slow, states are creating tools employers can use as leverage.
Themes I'm Taking Back
A few things cut across nearly every session:
The data access problem is not technical, it is contractual. Carriers and PBMs have structured agreements to deny employers access to their own claims data, and too many plan sponsors have signed those agreements without pushing back. The legal right exists. The practical path is negotiating it upstream, before the contract is signed.
Shoplifting is the hardest pattern to spot and the easiest to fix once you look. Most of the examples from this conference did not require sophisticated analytics. They required having a spreadsheet and sorting a column.
Direct care models are not a niche anymore. Direct primary care, surgical centers of excellence, direct drug procurement: these are mainstream strategies at employers with tens of thousands of covered lives. The infrastructure is accessible to mid-market employers in ways it was not five years ago.
Prevention beats recovery in payment integrity and in nearly everything else. The shared savings model that charges employers to correct errors in claims those same carriers approved is a structural conflict that should concern every plan sponsor. The answer is not to fight after the fact, it is to set the terms before you sign.
Lee Lewis has spent his career in employer benefits strategy, focused on getting American employers and the people they employ access to better, more affordable healthcare. Michael Berry came up through a service-based calling in firefighting and brought that same orientation to payment integrity, doing the hard work of identifying and fixing errors that most plans let slide. Nicholas Ade has been in a hospital bed watching his daughter's face and knows what it looks like when someone does not get the support they need. And finally, I'd like to give a shout out to Justin Leader as somebody who has been pushing the status quo in employer benefits for years, building a community bold enough to call out misaligned incentives and put together a world class agenda of speakers willing to do the same. Everyone in that room cared deeply about making a difference. The stakes are as real as it gets.
Based on my attendance at the BenefitsDNA Elevated Insights Summit, Harrisburg, Pennsylvania, May 14, 2026. Speakers: Lee Lewis (Health Transformation Alliance), Mike Berry (WellRithms™), Nate Erway (Verber Dental Group), Julie Selesnick (Judi Group, Health Plan Legal Counsel), Shawn Gremminger (National Alliance of Healthcare Purchasing Coalitions), and Nick Ade (Central Pennsylvania Youth Ballet). WellRithms is a registered trademark.