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.”

What Looks Simple… Isn’t

Healthcare billing is one of the most structurally complex pricing systems in the U.S. economy.

Let’s take just one example: a bone marrow transplant.

To properly price it, you’d need to:

• Parse dozens of DRGs, CPTs, and revenue codes
• Know whether it’s billed under case rate, bundled episode, or percent-of-charge
• Factor in the contracted network structure, facility tier, and carve-out routing
• Overlay the benefit design, deductible status, coinsurance, and OOP max
• Understand if the patient was routed through a specialty network—and if that increased the cost

That’s one case. Now multiply it across every hospital, every claim, and every plan.

Still sound like a spreadsheet job?

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Why In-House Tools Fail (Even the Good Ones)

Even smart, well-staffed teams struggle with:

• Machine-readable files that are barely human-readable
• Inconsistent or unlabeled contract types
• Carve-out networks that aren’t disclosed in rate sheets
• COEs with huge price variation inside the same hospital system

You may have:

• Great claims analysts
• A solid BI tool
• A team that can pull historical spend

But what you don’t have is the infrastructure to:

• Normalize national price files
• Tag contract methodologies
• Predict stop-loss impact before it’s billed
• Flag steerage opportunities in real time
• Identify providers where you’re overpaying—for the same procedure

We do. Because we built it from the ground up to do exactly that.

What You Get With HealthRate

We’re not a dashboard. We’re not just a data tool.

We’re your specialized analytics partner for high-cost care and unpredictable claims.

Here’s what’s under the hood:

• Comprehensive analysis for transplants, gene therapies, and other catastrophic care
• Provider-specific cost comparisons across contracts and networks
• Steerage guidance to avoid overpaying at so-called “preferred” providers
• Real-world cost estimates with benefit design included
• Stop-loss exposure projections and mitigation opportunities

You can’t build that in Excel. And you shouldn’t have to.

Don’t Build the Tool. Use It.

We’ve already done the hard part:

• Ingested the data
• Solved the math
• Built the models
• Coded the logic
• Validated it against real claims

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So instead of trying to duct-tape a DIY solution…

Let us run a free exposure analysis for you.

See how HealthRate turns “hard-to-use data” into a risk strategy you can actually act on.

Because when it comes to catastrophic claims:

Don’t try this at home. Let us handle it.