Don’t Try This at Home: Why DIY Catastrophic Claim Analysis Is Riskier Than You Think

With the rise of healthcare price transparency, open-access data, and AI tools, it’s easy to believe: “We’ve got smart people. We can probably handle this in-house.” We get it. On paper, transplant claims, gene therapies, and bundled pricing don’t look that complicated. But in practice? It’s like watching a YouTube tutorial and deciding to rebuild your transmission. That’s why at HealthRate, we have one simple message for employers, brokers, and TPAs trying to model catastrophic claim risk on their own: “Don’t try this at home.”

In philosophy, the Lottery Paradox asks: If you know one ticket will win, but each ticket is unlikely to win, is it rational to believe each ticket will lose? It’s a cautionary tale about how we misjudge low-probability, high-impact events. In healthcare, self-funded employers fall into the same trap every day, especially with organ transplants, gene therapies, and CAR-T treatments. The cost of this thinking? Seven-figure claims that blow past stop-loss.

HealthRate, an award-winning SaaS application specializing in comparing network contracted rates for high-cost medical cases such as transplants, CAR-T, and gene therapy, is proud to announce its integration with the Scientific Registry of Transplant Recipients (SRTR) quality data.

At HealthRate, we’ve developed an AI-driven solution specifically designed to interpret and ingest provider contracts, a task that’s historically been complex, time-consuming, and error-prone.

In the wake of growing regulatory scrutiny and a wave of class-action lawsuits, plan sponsors — especially self-funded employers and their advisors — are under increasing pressure to prove they’re acting in the best interest of plan members and spending wisely. Nowhere is that pressure more intense than in catastrophic care, where single claims can reach $2 million or more.

HealthRate has built a platform that makes something previously complex remarkably simple: finding the lowest-cost, highest-value providers for high-dollar medical procedures like organ transplants, complex oncology, cell and gene therapies, and bone marrow transplants.

The total cost of care (TCOC) is staggeringly variable, even for the exact same treatment, at the same provider. This hidden volatility poses a major risk for stop-loss carriers, MGUs, and self-funded employers managing high-cost claims.

HealthRate is honored to announce that we have been named Best in Show in the Emerge Innovation Experience Contest at HIMSS25 for our groundbreaking work in Improving Data & Analytics Capabilities and Reach in the Payer category. This prestigious recognition underscores our commitment to transforming healthcare by delivering data-driven insights that address critical challenges in today's medical landscape.

What if the data you're relying on is leading you astray? Simpson’s Paradox has a sneaky way of flipping the script in healthcare cost analysis—making the "best" contracts look like the worst (and vice versa). In high-stakes carve-outs for transplants, oncology, and more, this misinterpretation can cost millions.

The increasing cost of healthcare is creating serious financial risks for businesses across the board. High-cost claims, especially those related to transplants, oncology treatments, and advanced therapies like gene and cell therapy, are becoming more frequent and expensive.

The escalating costs of medical claims, especially for transplants, are putting increasing pressure on the healthcare system, forcing payers and providers to find more sustainable solutions.

For Managing General Underwriters (MGUs), the ability to effectively manage catastrophic claims is a key differentiator in a highly competitive market. As healthcare costs continue to rise and catastrophic claims like transplants, oncology treatments, and advanced therapies grow more frequent, MGUs must implement smarter strategies to stay ahead.

The cost of healthcare premiums continues to rise, placing increasing pressure on employers across the United States. According to the Kaiser Family Foundation (KFF), the average annual premium for employer-sponsored family health coverage rose to $22,463 in 2023, marking a 7% increase over the previous year.

The financial pressures of managing high-cost claims like transplants, oncology treatments, and advanced therapies are well-known, but there’s another challenge that businesses face when dealing with these claims: the overwhelming administrative burden.