Mismanagement of Self-Funded Health Plans

Name: Turnbull, Moak & Pendergrass, PC
Telephone: (888) 488-9616

High-stakes ERISA cases require more than technical knowledge; they require trial-ready advocacy. Turnbull, Moak & Pendergrass, PC brings a trial-first discipline to fiduciary breach litigation, confronting institutional defendants head-on. With over 125 trials and eight-figure verdicts to our credit, we hold Third-Party Administrators (TPAs) accountable for claims mismanagement and self-dealing. ERISA sets the rules; we have the experience to enforce them.

ERISA Sets the Rules. Turnbull, Moak & Pendergrass Enforces Them.

Turnbull, Moak & Pendergrass, PC is a national trial firm known for handling complex, high-dollar cases where the stakes are real and the opposition is powerful. With more than 125 trials taken nationwide, verdicts reaching eight figures, and extensive experience litigating against institutional defendants, we are well-equipped to confront fiduciary misconduct head-on.

When fiduciary duties are breached, accountability is not negotiable. Contact Turnbull, Moak & Pendergrass, PC for a confidential consultation today.

Additional Sources

29 U.S.C. § 1104(a)
29 U.S.C. § 1106
Enforcement | U.S. Department of Labor

close up of woman's face looking distressed

When Claims Administration Becomes a Fiduciary Issue

Under the Employee Retirement Income Security Act of 1974 (ERISA), an entity that exercises discretion over claims adjudication, pricing, or plan management may be treated as a fiduciary, regardless of how it is labeled in the administrative services agreement.

ERISA fiduciaries are legally required to act solely in the interest of the plan and its participants, using care, loyalty, and prudence, and to avoid conflicts of interest or self-dealing.

These obligations are enforceable legal duties. When TPAs deviate from them, whether through systemic overpayments, pricing manipulation, or undisclosed financial arrangements, plan sponsors may face both economic loss and regulatory exposure.

Why TPA Misconduct Requires Litigation-Ready Enforcement

TPA-related ERISA cases are fundamentally different from routine benefits disputes. They often involve:

High-volume claims data spanning years
Complex pricing methodologies and internal systems logic
Financial arrangements not disclosed to plan sponsors
Institutional defendants with significant resources

Identifying misconduct requires more than surface-level audits. Enforcing accountability often requires full-scale litigation, including aggressive discovery, expert analysis, and the ability to withstand pressure from well-funded adversaries.

This is where trial capability matters, not as marketing language, but as a practical necessity.

How Turnbull, Moak & Pendergrass Approaches TPA and ERISA Cases

Turnbull, Moak & Pendergrass, PC represents plan sponsors, public entities, state attorney general's, and institutional employers in ERISA fiduciary litigation involving TPAs, insurers, and healthcare intermediaries. Our role in these matters is not advisory. It is investigative and enforcement-driven.

We focus on uncovering:

Systemic claims mismanagement
Improper pricing and reimbursement practices
Undisclosed self-dealing arrangements
Data withholding that prevents fiduciary oversight

Our trial experience is applied where it matters most, after the misconduct is identified, and accountability must be enforced in court.

Our Roster of Attorneys The Trial Team Insurance Companies Don’t Want on Your Case

Attorney Brett Turnbull

Attorney Andrew Moak

Attorney Philip Pendergrass

Attorney Ben Brown

Attorney Benjamin A. DuBose

Attorney Bobby LeMoine

Attorney Brett Hollett

Attorney Callie Brister

Attorney Chloe Panaccione

Attorney Drew Haskins

Attorney JD Lawrence

Attorney Kyle R. Jackson, Sr.

Attorney Will Lattimore

Attorney Zach Peagler

Attorney Josh Bauer

Attorney J. Curt Tanner

Attorney Bruce Downey

Attorney Jake Norwood

Attorney Nick Mucerino

Attorney Nhan Nguyen, MD, JD, MSF

Attorney Steve Rosen

Consult With Us See All Attorneys

How We Investigate Systemic Claims Mismanagement

Courts do not rely on labels written into administrative contracts. They look at what the TPA actually does. When an administrator controls how claims are priced, approved, paid, or audited, it may be deemed a functional fiduciary.

Turnbull, Moak & Pendergrass, PC represents plan sponsors in cases alleging TPAs breached their ERISA obligations through repeatable, systemic misconduct, including:

Paying More Than the Provider Billed

Approving and paying claims in excess of 100% of billed charges
Draining plan assets without justification
Violating basic fiduciary prudence

Paying for Services Never Rendered

Authorizing payment for care that never occurred, which is a breakdown that no prudent fiduciary system should allow

“Flip Logic” and Pricing Manipulation

Using internal claims-processing logic to reimburse out-of-network claims at full billed charges rather than negotiated or Host Plan rates
Doing so produces massive overpayments hidden from plan sponsors

Approval of Medically Impossible Claims

Automatically approving claims that should never pass a competent adjudication process, including:

Mutually exclusive procedures
Excessive surgical units
Services billed simultaneously in violation of medical reality

These failures directly contradict CMS coding and billing standards.

Duplicate Payments

Paying for the same medical services multiple times across fragmented systems, without detection, reconciliation, or recovery

Upcoding and Unbundling

Failing to prevent providers from:

Billing higher-level services than those rendered (upcoding)
Fragmenting procedures to inflate reimbursement (unbundling)

Hidden Revenue Streams and Self-Dealing Schemes

Beyond claims errors, recent ERISA complaints reveal deliberate profit-extraction models designed to convert plan assets into revenue for administrators. Turnbull, Moak & Pendergrass investigates allegations involving:

Cross-Plan Offsetting

Recovering overpayments made on other plans—including fully insured plans—by withholding funds owed to providers from your self-funded plan’s assets, without authorization or disclosure

“Shared Savings” Arrangements

Mandatory programs where TPAs retain 30–50% of alleged savings generated by identifying errors—errors that the TPA often allowed to pass through initially
Such arrangements may constitute prohibited transactions under 29 C.F.R. § 2550.408b-2

Dummy Codes and Concealed Fees

Using non-standard or “dummy” CPT codes to route plan assets to subcontractors
Masking the actual cost of administration and undermining transparency

Variance and Suspension Accounts

Withholding refunds and overpayments in internal accounts instead of returning those funds to the plan, where ERISA requires they belong

Why TPAs Resist Transparency

Plan sponsors cannot fulfill their fiduciary obligations without access to their own data.
Yet TPAs routinely refuse to produce claims data, labeling it “proprietary” or demanding restrictive confidentiality agreements designed to prevent scrutiny.

The Consolidated Appropriations Act of 2021 (CAA) prohibits “gag clauses” that restrict a plan’s access to cost, pricing, and quality-of-care data (Gag Clause Prohibition Compliance Attestation | CMS).

Blocking access to claims data may itself constitute:

A breach of ERISA fiduciary duties
Interference with a plan sponsor’s duty to monitor service providers

Turnbull, Moak & Pendergrass enforces data transparency, follows the money, and builds litigation-ready cases from the records TPAs hope never surface.

Is Your Third-Party Administrator (TPA) Mismanaging Your Self-Funded Plan?

Employers that sponsor self-funded health plans rely on Third-Party Administrators (TPAs) to accurately price, adjudicate, and pay medical claims. In many plans, TPAs effectively control millions of dollars in plan assets, making their role central to the financial health of the plan.

Recent litigation and regulatory scrutiny have revealed a growing concern: some TPAs are prioritizing internal revenue streams and cost-shifting practices over the interests of the plans they administer. These practices can quietly drain plan assets through overpayments, improper pricing logic, and undisclosed fees, often without meaningful visibility for plan sponsors.

When these issues arise, they are not simply administrative problems. They raise serious fiduciary compliance and liability questions under federal law.

Do You Have a Claim Against Your TPA?

If you sponsor a self-funded plan and suspect your administrator is mismanaging claims or concealing information, you may have grounds for legal action, including:

Breach of Fiduciary Duty: For failing to act with loyalty and prudence in managing plan assets.
Prohibited Transactions: For self-dealing arrangements such as shared-savings fees or cross-plan offsetting.
Breach of Contract: For ignoring negotiated discounts or violating the Administrative Services Agreement.
Fraud or Constructive Fraud: For concealing pricing methodologies, conflicts of interest, or known payment errors.