Employer file · oversight before benchmarking
Make denial behavior a benefits-governance question.
Employers pay for care, select administrators, and absorb the human and financial cost when a denial creates delay. The public data is useful for oversight—but it does not reveal what is happening inside a specific employer plan.
Evidence boundary
The public file has a deliberate blind spot
The federal datasets on this site cover Medicare Advantage, Medicaid managed care, and individual marketplace plans. They do not measure claim denials or prior-authorization outcomes inside a self-funded employer plan.
That means a public carrier ranking cannot answer the most important fiduciary question: what is this administrator doing to our members, under our plan design, with our money?
Start with the plan type
First, identify who pays the claims
There are two common employer arrangements. In a fully insured plan, the insurance company pays claims and the state insurance department regulates the policy. Some states publish useful insurer reports, but the measures and years vary. In a self-funded plan, the employer pays claims from the plan's money and usually hires an administrator — often called a TPA — to process claims and appeals. The TPA has the operational data, but there is no national public denial-rate table for self-funded plans.
The employer, not a public Marketplace file, is the starting point. Ask the insurer, TPA, broker, and pharmacy administrator for a de-identified plan-year extract. The employer can share aggregate or de-identified records under a data-use agreement; we do not need member names, member IDs, diagnoses, or full medical records.
The federal Transparency in Coverage files are useful for negotiated prices and allowed amounts. They do not tell an employer how many of its members were denied, appealed, or had a denial changed.
Current offer
What is available now
Carrier disclosure briefing. A sourced review of the administrator's public denial behavior, disclosure quality, and known data gaps—kept separate by program and decision type.
Governance question set. A practical agenda for a benefits committee, board, consultant, or administrator review: volumes, reasons, appeal rates, overturns, reviewer credentials, automation, delegated entities, and access to plan-level records.
Plan-specific denial audit. For employers able to provide de-identified plan data under appropriate agreements, we can normalize claims, prior authorization, and appeals into one plain-language scorecard. This is not yet an automated product, and the public index is not a substitute for that audit.
A practical paid engagement
What a paid employer review would deliver
1. Secure intake. We map the plan year, funding type, insurer, TPA, pharmacy administrator, delegated vendors, and the files available.
2. A clean evidence table. We separate claims denied after care from permission denied before care. Every rate keeps its count, definition, source file, and missing fields.
3. A member-impact readout. We show how many decisions were denied, how often people appealed, how often the decision changed, how long decisions took, which reasons created the most volume, and where automation or delegation enters the process.
4. A board-ready action plan. The employer gets questions for the TPA or insurer, correction and escalation triggers, a renewal scorecard, and a record it can use when deciding whether to change vendors.
This can be a one-time baseline, a quarterly monitor, or a recurring vendor scorecard. The price should follow the data volume, number of plans, and reporting cadence—not a promise of a single universal “best insurer.”
Committee agenda
What to ask your administrator
1. How many claims and prior-authorization requests were denied, separately, in the last plan year? 2. Which denial reasons account for the most member impact and spend? 3. What share was appealed, and what share of appealed decisions was changed? 4. Which decisions were automated, algorithmically recommended, or delegated to another entity? 5. Can the employer receive a de-identified, claim-level extract and the governing denial-reason taxonomy? 6. Who owns correction, escalation, and member remediation when a pattern is found? 7. Is the plan fully insured or self-funded, and who actually paid each claim? 8. Which fields are missing because the administrator does not collect them, and which are missing because it will not release them?
If you are evaluating a carrier, preparing a committee discussion, or exploring a plan-specific audit, describe the plan type, administrator, member count range, and decision you need to make.
Email the project