Looking Back and Looking Forward
Review of 2025
I really look forward to writing this article each year. Who you trust your health plan with is a huge decision, and I feel I owe you information. It was a massive year for ClaimDOC and the reference-based pricing industry in 2025 and here is what tops our list:
- Growing industrywide momentum and support for nontraditional solutions
- ClaimDOC shut down new sales
- Pave the Way® continues to change the market
Nontraditional Momentum
About a year and a half ago, I ran into Mark Cuban in the Bahamas. Mark was polite, but as I squeezed in “that’s Krambeck, with a ‘K’’ as the hotel elevator door shut in my face and he ventured on up to his suite, that’s where I thought our relationship had ended. And really that’s where it did end, except for the fact that Mark went bananas in 2025 about the messed-up health insurance industry.
I would never compare myself to him, and we already have way too many voices in our space that self-aggrandize, but he is feeling like I felt when I founded the company in 2013. Some of us are wired that we can’t stop thinking about it once you see the shameful behaviors and grasp what’s happening to working-class Americans because of it. If you want to be disgusted, think about how many people with power and control just don’t care. Brokers, politicians and insurance executives lead the way. I’ve softened my stance with hospital executives over the years. Brad Hansen, our vice president of provider relations and former hospital administrator, has educated me more on all the land mines and complexities the systems and facilities are dealing with. Maybe I’ve matured, but now I’m slower to broad brush a category based on a small percentage of bad actors.
You’ve likely heard me say this before, but as much as I admire the big voices in our small space, the power of change lies with the big brokers. Nationally, firms like Aon, Marsh, Mercer, Willis Towers Watson, Hub, Gallagher, Brown & Brown, and Lockton will positively impact the most lives through their willingness to consider alternatives in combatting the unaffordability of medical benefits. We have strong and growing relationships in this space. However, the big firms still seem to be finding their footing when it comes to discretion on vendor selection. I’m not too proud to change if it means more of the working class will get access to a well-executed RBP solution with ClaimDOC.
ClaimDOC Shuts Down New Sales
In October, Omar Arif, senior vice president of growth, announced to our partners that we were pausing new sales. Pretty much everything you need to know about the move was in the article. To me, this represented what is best about our company. Money is not our master. Yes, we need it to innovate and support the resources needed to operate our comprehensive version of RBP, but it doesn’t control us.
This was a highly conservative move on our part. Our team had more capacity, however, despite all the technology supporting our solution, there are still humans at the heart of it. Humans speaking to providers; humans speaking to members; and humans holding the hand of a human resources leader new to RBP. Nuances existed with our committed cases that made us believe the work rate would be higher than what our traditional metrics told us.
We won’t sacrifice our values — our commitment to execute the program at a high level or our commitment to taking care of our people. If you take one thing from this article, it’s this: in 13 years we have never had an account manager leave. Our account managers are the hub of the experience for our clients. They are air traffic control usually juggling more things in one day than I deal with in a month. We aren’t perfect at rightsizing their caseloads, and sometimes they get stretched, but they always know we have their back.
Proactive Provider Outreach Is Changing the Market
Our Pave the Way statistics from this past year demonstrated both the need participants have and the expertise we execute with. In 2025, we completed 26,204 provider nominations with a participation rate of 96.3%.
We added Mike Trent to our sales team this past fall. Mike is a veteran RBP salesperson, and in one of our first conversations, he shared the only thing he feared when selling to brokers was them asking about proactive provider outreach. He knew ClaimDOC is the only one willing to commit to doing this effectively. To understand why they won’t commit to proactive outreach, you have to understand that it’s extremely costly and extremely hard to do it well. We just make it look easy.
I don’t know how to say this and not sound off-putting or arrogant, but a broker choosing to work with our competitors instead of ClaimDOC is a testament to the power of ignorance. The financial incentive around RBP requires removing the vast majority of network/contracted access. If you are removing contracted access, would you rather have a proven program that proactively educates providers and removes the friction, or would you rather have your employees be responsible for this?
The answer is obvious, and it has forced a shift in the RBP market. Competitors are no longer pretending they will commit the resources necessary to facilitate a network-free environment. They’ve gone through the stages of denial — from saying ClaimDOC doesn’t actually do it, to it doesn’t actually work, to they will do it, and to finally acceptance of we have a tool they will never have. Now, they are shifting their focus to contracts, which will take plan sponsors right back to where they started. On one hand, I’m proud of our company. But on the other hand, I’m disappointed our competitors are not fighting to do what’s right and not operating with a purpose.
Looking Forward to 2026
Stop Loss
This year will be a transformational year in medical stop-loss reinsurance. Sam Apland wrote a great article this fall on issues impacting renewal rates. Large insurance companies’ appetite for risk always has ebbs and flows. It’s considered a hard market when market conditions stress their book of business and they become focused on de-risking via high premiums, strict underwriting and more exclusions. Last year was bad, but 2026 will be even worse. Two large reinsurers are in the process of exiting the medical stop-loss market, providing a clear signal of how bad 2026 will be.
Thank your broker for placing you in an advantageous position by having guardrails on your medical spend. I’m not suggesting you’ll get full credit for your cost-containment efforts, but plan sponsors without effective controls on medical costs will be lambs to the slaughter.
Fiduciary Buzz
I’m proud to say we were fiduciary before fiduciary was cool. This has never been a move to appeal to the market, it’s in our beliefs and it’s reflected in every element of our program. Being a fiduciary isn’t about a title, it’s about your behaviors. In the RBP space, formerly known ELAP Services was the only other company that had the behaviors of a fiduciary, and I respected them for that. Now they are Imagine360, and they are bundling up to be the third-party administrator, network and pharmacy benefit manager. This path for revenue is a layup from a business operator perspective, and this will continue to be a trend in our space that we will not follow.
In my opinion, this doesn’t align with being a fiduciary for two reasons. Bundling has always been a source of hidden profit centers and opaqueness. Bundling removes the checks and balances that exist with our independent TPA partners. It makes for a great sales pitch and is excellent for creating a moat around your clients, but that isn’t who we are.
The Cost of Doing It Right
I would love to meet all our clients but, unfortunately, people aren’t lining up to fly to Des Moines. It’s a special environment that has organically evolved here at our headquarters, and the energy matters. I think both the formal and informal leaders have done an excellent job of creating transparency and authenticity around how much we all care about our work. That commitment ignites the spirit of employees at every level and creates the culture we have today. Our office is a place of learning, collaboration, hard work and community.
I mentioned the human aspect previously. We continuously see that despite the world moving away from human interaction, it’s needed now more than ever in our space. We have committed to growing our staff in line with new business, and we’ve aligned staff growth almost perfectly on that growth plane.
Our belief in the power of human interaction isn’t cover for a lack of technology. The technological demands required to properly support a fully integrated and comprehensive RBP solution have exploded since 2020. Here is a look at our technology spend.
The best possible experience without a network is our goal. And even though we are already considered the gold standard, we will continue to invest to make it even better — investing in people and investing in technology. The underlying jet fuel we possess is the situational knowledge of executing all phases of network replacement for 13 years. Knowledge is much different than experience. Knowledge is shared through intense teamwork with the goal of not just solving a problem but operationalizing that solution so others can learn from it.
Conclusion
I mentioned earlier that the RBP competitor landscape is changing quickly. There is only one competitor that goes by their original name, and their private equity ownership group doesn’t have them focused on network replacement anymore. RBP was originally built on a foundation of passion and purpose. Now it’s like someone posting on Instagram about loving their kid’s band concert, but they don’t let their kid practice their trumpet in the house. They don’t love executing RBP, their staff isn’t immersed in overcoming challenges and there is no pride. It’s nontransparent revenue shares, sales gimmicks on balance bills, and staff with overlapping roles across multiple lines of business.
ClaimDOC wasn’t founded because my family or my company made a lot of money in an adjacent business and we could parlay that into more revenue by branching off into RBP. I got into this space because egregious and unchecked claims were going to put my captive out of business. That mindset is what drove me to found ClaimDOC 13 years ago and what still drives us to continuously evolve and innovate while staying true to why clients need us.