New Transparency Rules Put Big Healthcare Insurance Networks Under Scrutiny

Vxtra Health CEO and Founder Larry Hightower says self-funded employers can use newly accessible pricing data to test if national network contracts are delivering what was promised while considering more transparent, locally led alternatives.

ATLANTA, Nov. 9, 2026 — Self-funded employers bear the financial risk of claims paid through their health plans, making discrepancies between negotiated healthcare prices and actual payments a potential source of unnecessary spending. On October 5, the Centers for Medicare & Medicaid Services (CMS) finalized changes to the Transparency in Coverage rules intended to make healthcare pricing data easier to locate, compare and evaluate, giving employers more information to examine how their plans are being administered.

Opaque contracts, fragmented claims systems, and limited payment reconciliation have made it difficult for self-funded employers to verify if negotiated terms are being carried through to actual payments. Larry Hightower, founder and CEO of Vxtra Health, a healthcare company built around a physician-led methodology for managing employer health plans, argues that greater transparency can help employers understand where costs are accumulating and question the national network arrangements behind them. "The contract terms are written to favor the big insurance companies and the big hospitals," Hightower said.

Transparency Can Expose Gaps Between Contracts and Payments

A negotiated healthcare price does not guarantee that every claim will ultimately be paid according to that agreement.

Hightower describes bundled surgical procedures as one example. An employer may believe it has negotiated a single price for a knee surgery, only to find that disconnected carrier billing and payment systems failed to enforce the agreement, allowing individual components to be billed and paid separately. The employer can end up paying substantially more than the contracted price while the carrier responsible for administering the agreement fails to catch or correct the discrepancy.

Under the Affordable Care Act's Medical Loss Ratio (MLR) rule, insurers in the large-group market generally must spend at least 85% of premium revenue on medical care and quality improvement, while self-funded plans themselves are not subject to that requirement. Hightower argues that when large carriers operate across both fully insured and self-funded businesses, their financial interests may not always align with a self-funded employer's goal of aggressively reducing claims costs. "There is no contract-to-payment integrity being verified by the big carriers," Hightower said.

Employers Have to Know What Happens After the Contract Is Signed

As more pricing and claims information becomes available, self-funded employers have more opportunities to examine how their plans are being administered. That means looking beyond total spending to the records behind it, including contract terms, claims data, administrative charges and the methods used to calculate payments.

Hightower compares the process to an independent financial audit. Employers need to obtain the records to understand how payments were calculated, investigate discrepancies, and document what action they take in response. The point of transparency is to give employers enough information to oversee the plan rather than simply receive a report after the money has already been spent.

For years, Hightower argues, opaque contracts and gag clauses have limited employers' ability to examine fees, payment practices, and other terms affecting plan spending. "Why would you put a gag clause in a contract when your responsibility is to manage somebody else's money?" Hightower said.

Healthcare Is Local. Network Accountability Should Be Too

Identifying a discrepancy is only the first step. Hightower said employers should question whether a national network built to serve many markets can provide the level of contract oversight, physician involvement and local accountability needed in their own community.

Hightower focuses on middle-market self-funded employers in secondary markets, where he plans to build transparent contracts around local physician networks. Those physicians can add clinical context when claims reviews surface unusual payments, explain what care was delivered, and help employers evaluate if billing aligns with the services provided. That physician involvement works alongside claims review, contract monitoring, and plan oversight, so findings can influence how healthcare is purchased and managed within the local market.

"We're not just closing the books and saying, 'We discovered your problems.' We're showing you how to get it fixed," Hightower said. "We are the anti-health insurance company, for a reason."

References

• Centers for Medicare & Medicaid Services. (2026, October 5). Transparency in Coverage final rules (CMS-9882-F). cms.gov/newsroom/fact-sheets/transparency-coverage-final-rules-cms-9882-f
• Centers for Medicare & Medicaid Services. (2026, October 5). New regulations make it easier to find, compare, and report healthcare pricing and coverage information. cms.gov/newsroom/press-releases/new-regulations-make-it-easier-find-compare-report-healthcare-pricing-coverage-information
• Centers for Medicare & Medicaid Services. (n.d.). Medical loss ratio data and system resources. cms.gov/marketplace/resources/data/medical-loss-ratio-data-systems-resources

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SOURCE Vxtra Health