"[AI] absolutely is an arms race, and this is what we're dealing with on a daily basis." - Stephen Carrabba, ClaimInformatics

In this episode of Last Month in Healthcare, Producer Nathaniel and I sat down with Stephen Carrabba, president and co-founder of ClaimInformatics, to break down the biggest healthcare news stories of September 2026.

We started with Blue Cross Blue Shield's claim that AI-powered medical coding tools added $942 million in costs over the past two years. One example: anemia diagnoses rose sharply at some hospitals with no matching rise in transfusions. The coding companies' response is that in a fee-for-service system, capturing a more complete picture of the visit means a bigger bill. Stephen deals with upcoding and unbundling every day. His take: if a service was rendered, it should be billed, but hospitals' AI and insurers' AI are now fighting each other, and the self-funded employer is the one paying for both.

We also dug into ICHRA's federal rebrand as the "CHOICE arrangement," a survey showing 73% of small and mid-size employers are considering dropping group coverage for 2027, and Oscar Health's projection of 2.5 million ICHRA lives by 2029. I shared the story of an employer who moved to ICHRA for $400,000 in projected savings and wanted out within a month.

Plus, more than half of hospitals still aren't fully complying with price transparency rules. Stephen explains why, for many health systems, paying the fine is cheaper than disclosing their prices.

To cap it off, we built two health plans by coin toss, where Stephen made the case against bundled payments from a payment integrity perspective. I also answered a listener question about how much of a stop-loss increase is normal before you should shop it.

Thank you to Walk-On Clinic for sponsoring this episode. Visit walkonclinic.com to learn more.

Chapters:

(00:00:00) Intro: Stephen Carrabba and Walk-On Clinic
(00:01:48) AI Billing and the $942M Fight
(00:04:51) ICHRA Becomes CHOICE
(00:07:49) 73% of Small Employers Weigh Dropping Coverage
(00:11:00) Oscar Predicts 2.5M ICHRA Lives by 2029
(00:12:13) Hospitals Still Dodging Price Transparency
(00:16:45) Game: Build a Health Plan by Coin Toss
(00:37:27) Ask Spencer Anything: When to Shop Stop-Loss

"We pay them a $2,500 flat fee for the time that they spend with the patient and make that recommendation for no surgery. If you don't, then you've wasted their time." - Matt Eurey

Most of healthcare is paid for volume, so employers end up paying for surgeries that never needed to happen. When RAND studied Carrum Health's data, about 30% of surgeries were avoided once the first step was checking whether the patient actually needed one.

Matt Eurey ran benefits at Lowe's, which spent about a billion dollars a year on healthcare. He explains how Carrum pairs bundled prices with surgeon-held warranties and charges nothing per employee per month. He also covers why more than half of Carrum's new buyers last year made the program mandatory, and how the model extends to cancer and substance use disorder.

If surgical and specialty claims are driving your trend, this is the episode for you. Tune in.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Paying Surgeons Not to Operate

(00:00:20) Meet Matt Eurey and Carrum Health

(00:01:56) How Carrum Decides if Surgery Is Appropriate

(00:05:34) Rooting Out Perverse Incentives

(00:07:01) Running Benefits for 225,000 at Lowe's

(00:13:26) The Early Days of Care Navigation

(00:18:49) Why Matt Joined Carrum

(00:20:50) What Value-Based Care Actually Means

(00:26:33) Why Carrum Doesn't Use Benchmarks

(00:28:44) Zero PEPM: How Carrum Gets Paid

(00:30:28) Mandated vs. Voluntary Programs

(00:37:01) Can This Become the Standard?

(00:41:01) How Claims Flow Back to the TPA

(00:43:17) The Member Experience, Start to Finish

(00:49:03) Cancer and the Two-Year Warranty

(00:51:45) Substance Use Disorder Care in Hours

(00:56:14) Why Carrum Added Cancer and SUD

(00:59:44) Why Wouldn't an Employer Do This?

(01:01:33) What's Next for Carrum

(01:03:10) What Happens If We Don't Fix Costs

(01:05:08) Closing Thoughts

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

"Over 90% of the time, there is some change recommended to the care path someone is on. Oftentimes we make two to four separate recommendations." - Peter Bridges, AccessHope

Cancer is one of the largest cost drivers in any self-funded plan, and most of the strategies built to manage it focus on price. Peter Bridges argues the bigger lever is making sure the patient is on the right treatment in the first place.

Only about 20% of cancer patients are treated at one of the country's 57 NCI-designated comprehensive cancer centers. The other 80% get care locally, from oncologists seeing a full schedule across multiple cancer types while the science moves faster than any one doctor can track. That gap shows up in outcomes, and it shows up in claims.

AccessHope closes it by bringing subspecialists from centers like Dana-Farber, Johns Hopkins, and Fred Hutch directly to the local oncologist. The diagnosis is identified in claims data, the treating physician is contacted, and the patient never has to travel, switch doctors, or ask for help.

We get into why lung cancer isn't a single diagnosis, why most local oncologists welcome an expert review rather than resist it, and why working-age adults now make up more than half of new cancer cases. Peter also explains why getting someone onto the right treatment early is the better financial decision for the plan, and what an employer actually has to do to put this in place.

If cancer claims are a line item you worry about every renewal, this is the episode for you. Tune in.

Thank you to our 2026 sponsors!

ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit https://www.paretohealth.com/fully-insured-vs-self-funding-with-paretohealth-spencer-podcast/?utm_source=youtube&utm_medium=referral&utm_campaign=SelfFundedwSpencer to learn more.

Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more.

Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more.

Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com.

Chapters:

(00:00:00) Intro: Bordering on Cruel

(00:05:12) Meet Peter Bridges and AccessHope

(00:11:40) The 80% Treated Outside Top Cancer Centers

(00:17:25) Lung Cancer Isn't One Diagnosis

(00:23:08) Finding Cancer Patients in Claims Data

(00:28:44) Inside an Expert Review

(00:34:30) Why 90% of Reviews Change the Care Path

(00:40:02) Why Local Oncologists Say Yes

(00:45:37) Cancer in Working-Age Adults

(00:51:15) Why the Right Treatment Is the Cheaper Treatment

(00:57:06) Putting It in Place as an Employer

(01:03:22) Stories From the Field

(01:08:40) Closing Thoughts

Key Links for Social:

@SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded

Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02

Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286

Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/

Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/