In this episode of The Uprising Show, we sit down with Kimberly Carleson, CEO of US Beacon, to uncover the hidden truths behind healthcare billing and the fight for transparency. Kimberly shares her personal journey, sparked by her husband's stage 4 cancer diagnosis and their firsthand experience with the flaws in the healthcare system. She reveals what drove her to take full ownership of US Beacon and make it her mission to tackle rampant overbilling. Listeners will learn why most employers are in the dark about their own benefit costs, the myths surrounding claims review processes, and the crucial steps every plan sponsor should take to bring genuine oversight into their health plans. Kimberly’s candid insights expose the misaligned incentives in the system, the secret world of hospital overcharges, and her vision for a future where billing transparency is the rule — not the exception.
Timestamps:
00:00 Buying 100% of U.S. Beacon
04:09 Reviewing company payment plans
06:34 HR moved from business side
11:48 Impact of DPC on providers
Unveiling the Truth About Medical Billing: Key Insights from Kimberly Carlson
Healthcare billing is often shrouded in confusion, with many employers and patients left unaware of the true costs lurking on their statements. In a recent episode featuring Kimberly Carleson, CEO of US Beacon, we gained revealing perspectives on what really happens behind the scenes, the hidden pitfalls in billing, and practical guidance for employers wanting to take control of their healthcare spend.
A Personal Journey Sparks a Mission to Fix Medical Billing
The turning point for Kimberly Carleson was deeply personal. While pregnant with her son, her husband was diagnosed with stage 4 cancer. The experience made her realize the extent of overbilling in the healthcare system. Owning an initial share of US Beacon, she decided to purchase the entire company with the mission to expose and address overcharging: "Once I realized how much overbilling there was, I told my husband I wanted to buy 100% of it." This passion quickly became her life’s work.
The Real Problem with Healthcare Billing
According to Kimberly Carleson, medical billing problems are multi-faceted. She explained that what employers often see as a controlled and managed process is actually "chaos disguised as controlled". Many employers believe that their claims are properly audited by their Third Party Administrator (TPA), but this is one of the most damaging myths. Kimberly Carleson compared it to "a fox in a henhouse", clarifying that TPAs typically only adjudicate claims, checking deductibles and pre-certifications, without reviewing each billing code for accuracy.
Overcharging is More Common Than You Think
One of the most shocking revelations in the interview was the scale of overbilling. Kimberly Carleson stated that she often sees 30 to 40 percent of in-network hospital bills consist of overcharges, and out-of-network bills can have over 70 percent in overcharges. Employers rarely realize this leakage until someone independent reviews their data. When overpayments are caught, clients are frequently surprised by how much money was unknowingly lost.
Taking Control: Where Should Employers Start?
For employers determined to reduce unnecessary spending, Kimberly Carleson advises starting with contracts. If your broker or consultant resists changes or lacks transparency, that is a red flag. She also emphasizes the importance of reviewing claims independently, stating, "It's good to get an independent, someone not connected to anyone on the plan to review your claims".
Specifically, she encourages employers to review their largest claims—particularly inpatient stays, hospital procedures, and pharmacy bills—where the greatest risk of overcharging exists. Employers should not ask for an "audit," but rather request to "review" their highest claims, since the industry too often provides handpicked claims for limited annual audits.
The Value of Data and Transparency
If Kimberly Carleson could grant employers one wish, it would be access to their own healthcare payment data, empowering them to make informed decisions and better control their plans. She cited a case where an HR manager, upon joining from the business side, questioned the lack of itemization on benefit payments and only then realized the need for more oversight.
Challenges and Solutions in the Industry
Brokers and providers are both part of the problem and the solution. While many brokers aspire to do good, misaligned incentives often keep them tethered to large insurance conglomerates. Additionally, providers help negotiate high rates and sometimes exclude payers unless higher fees are accepted. The hope is that as employers become more informed and providers adopt more transparent models, the industry will evolve in favor of cost control and integrity.
Conclusion
This episode highlights the urgent need for transparency, independent claim reviews, and courage to challenge the status quo. Employers must not accept vague assurances about claims review and should seek expert help to find genuine savings. As Kimberly Carleson is working tirelessly to change the world of billing transparency, her insights serve as a clarion call for employers and patients alike to demand more from the healthcare system.
For anyone navigating the complexities of healthcare billing, these takeaways from Kimberly Carleson’s interview are both enlightening and actionable. Start with the data, review your biggest claims, and never fear changing providers or consultants if you face resistance. By taking these steps, you can begin reclaiming control over your healthcare costs and ensuring value for every dollar spent.
The Uprising Show Website: https://theuprisingshow.com/
Vivek Nanda's LinkedIn: https://www.linkedin.com/in/viveknanda1/
Vivek Nanda's Twitter: https://x.com/vickks
TopHealth Media Website: https://tophealth.care/
“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
[00:00:00] What's the case, the bill or the patient that made you go, someone has to fix that? So my husband was diagnosed with stage 4 cancer and I was pregnant with my son at the time. I was told to Kim he's got a good two years while I was four months pregnant and I looked at that doctor and fired him. We owned 15% of U.S. Beacon. Once I realized how much overbilling there was, I told my husband I wanted to buy 100% of it.
[00:00:26] I'm Kimberly Carlson. I am CEO of U.S. Beacon. All right, Kim. So let's go back. What's the case, the bill or the patient that made you go, someone has to fix that? I think it's a mixture of all three. I think when you see the bill and you see the arrows on it, you can't unsee it anymore.
[00:00:51] When you hear the fear in the patient's voice, it makes you want to help them even more. And so I think that it's a mixture of the bill, the patient and the... The number. The number, right. Oh, and when you know that it's overcharged. And was it for you like somebody you saw whom somebody got a surprise bill and that was the reason like, you know, I'm going to start digging in this data and stuff. It was my husband. We were a part of the system.
[00:01:20] And so I knew something wasn't right. Yeah. Okay. And we were talking before how you ended up starting your company. Let's talk about that. Give us a little moment how you ended up starting the company. So my husband was diagnosed with stage four cancer. And I was pregnant with my son at the time. I was told, Kim, he's got a good two years while I was four months pregnant. And I looked at that doctor and fired him. And I went and found one on my team.
[00:01:50] I started realizing how health care was run because we were part of the system at the time. We owned 15% of U.S. Beacon. Once I realized how much overbilling there was, I told my husband I wanted to buy 100% of it. We bought 100% of it and it has become my passion from day one. So that's where we are. And how big is the operation now? So we have grown to 40 employees.
[00:02:20] We are in Little Rock, based in Little Rock, Arkansas, but we have employees all over. And we do bills in all 50 states. All 50 states. Wow. And, you know, you expose that gap between really what's billed and what's old. So where does an employer who's actually taken control of this from the start?
[00:02:48] Or I guess where does an employer who's really looking to take control of this, where should they start? They should start with their contracts. If you have someone that will not change your contract, then find someone else. It's kind of like the doctor that would not tell me to let my husband die. In two years, I fired him. If someone's not on your team, then find someone that is.
[00:03:14] But who's looking at, I guess, contractors there for sure, but who's going to tell them, looking at the bill, like, hey, is this even correct? Like, is that the part you're already saying covered to your contracting or somebody in their team needs to be the person who's finding out? Sometimes someone in their team needs to be the person. But really, it's good to get an independent, someone not connected to anyone on the plan to review your claims. And to be kind of the overseer.
[00:03:44] We kind of call it the check the checker of all the people within the system. Yeah. Because there are misaligned incentives in health care, unfortunately, inside and outside of your plan. And your company and your business, are you assisting this exact thing with your clients or when do you exactly get involved? I get involved whenever the plan reaches out to me.
[00:04:12] If they want me to look over, I will look within the plan. I can tell pretty quickly if there's someone within the system that could be not in the best interest of what's right for the system. So we will go within and look at who's paid where. Or if we have someone that's really wanting to work and build a great plan for the company, then we start reviewing the claims outside of it.
[00:04:40] Got it. And what's the most common, let's say, the billing myth that, you know, quietly costing money to employers? That your TPA already has a claims review in place. Do they? That's like a fox in a henhouse. No, they do not. They adjudicate claims. Adjudicating claims is totally different.
[00:05:05] Adjudicating claims is making sure that the member's deductible is met, making sure that their pre-certification was done. I mean, that's a total, they're not looking at every single code on the plane. And that's where we step in and look at all the codes and find all of the ineligible charges. When you, let's say, recover an overpayment, do people realize how much money was leaking?
[00:05:30] Like, or is it always like, yeah, we know it's happening. Or it's more like, oh, no, we never knew that. They are like, oh, no, we never knew that. And so when we're first reviewing claims and we begin our contracts, we'll like say, do you want a PPM or do you want a percentage of savings? They want a percentage of savings because they think we're not going to find anything. Well, then they start seeing how much we find.
[00:05:54] And they want to switch over to a PPM because they see that their percentage of savings is significant because we're finding so much. If, let's say, you had a magic wand, right? So if you could give that magic wand to employers, what would that be? Their own data. They would be able to get their own data anytime they wanted and that they would take control of their plan. But would you see any employer asking for data?
[00:06:23] I haven't, like, ever heard. Unless some external organization like yours get involved, then there is. But I haven't seen in status quo people even, they don't even know if there is. You know what's funny is I have one group out of North Carolina that the HR left. And I love HR. There's many great ones, but they moved someone from the business side over. And the first time they asked her to write a check, she said, where's the receipt? What am I writing the check for?
[00:06:53] And they said, the benefits. And she said, well, I need to see an itemization. And they said, no. So that's when she knew she had to reach out to someone to realize how to work this system in order to be able to see what she's writing the checks for. Wow. You know, that's what it is. If an employer audits, let's say, one thing on their claim side tomorrow, what should that be?
[00:07:19] Inpatient stays, hospital stays, outpatient surgeries, and pharmacy. That's where your largest overpayments are. Are your inpatient hospital stays and your outpatient surgeries, your ER visits, things like that. And you were saying something about audits and claims. I would like you to point out that distinction, too. Sure.
[00:07:43] So if you are, I would take 10 of your highest paid claims or even five and review them. Ask to review them. Do not say the word audit. Say, I want to review five of the largest claims. As a fiduciary, you should be able to review five of the largest claims. Once you review them, that's going to give you leverage to go back in because you only have one audit a year of randomly selected.
[00:08:10] I say randomly selected, but let's just go ahead and call it like it is. Handpicked claims for you to audit. They do not give you what they should give you if you're auditing. And it takes them eight months to give you that audit. So, like I said, handpicked. So you would go in, tell them you want your top claims to review, review those, and go from there. Much needed nuance. That's, everyone should know that.
[00:08:40] I want to now jump into the rapid fire round where I'll ask you a question and give the answer whatever first comes to your mind. So, where are medical billing today? Where is medical billing today? Is it chaos or control? Chaos disguised as control. Oh, you'd say disguised as control. Why? It's disguised as control.
[00:09:07] Like the Bukas think that they control. Yeah. It's in control. They've already got your review in place. Yeah. Roughly how much of a typical hospital bill is actually owed? I would have to see the itemized statement in UVO4. If you have to just give, is it possible to have some guesstimate? Like on an average, that's what you see? Percentage wise? Well, typically I see 30 to 40% of overcharges.
[00:09:35] On in network, out of network, 70% above. What would you say is the most overhyped cost containment fix? That they already have a review in place. One word for the state of billing transparency. Non-existent. Are you planning to change that for the world? What? Am I planning to change non-existent? Yeah.
[00:10:03] I'm working very hard to. Yeah. Yeah. All right. Cool. That's it. Anything you would like to add from your end? Anything that you want to add? Say? My biggest thing is for plan sponsors, if you talk to your broker and you say you want to review the claims and you have any type of pushback, realize that's for a reason.
[00:10:29] And know that there is a reason they are pushing back and find another broker or consultant. Yeah. Okay. Yeah. Makes sense. Do you think like the biggest challenge is like the conflict the brokers have? They want to do good, some of them at least. But they are still always going to be somewhat misaligned with what is actually going to be the fix, right? I have a lot of broker friends. Yeah.
[00:10:58] But I'm saying, do you see this conflict in them? Is it a daily conflict kind of thing? I think it is. I think that they want to do the right thing, but in the end, they stick with UHCs, the anthems, the Etna's. Yeah. They stick them in there somehow because ultimately their broker works more for the booker than they do the plan. Yeah. Yeah.
[00:11:25] I guess the big question is, can this be, the balance be shifted someday? There's a lot that are starting to do the right thing and I think they're going to be recognized a lot more. However, once people start seeing the savings and it gets, the talk goes around, it's going to be you either fix it and get clients or you don't have clients. I guess the way to look at it is how much change is going to happen on how providers are practicing
[00:11:55] because then they're going to demand that if I'm a DPC, I want to get you out of this thing. Then broker will have more share of this work and then that changes hopefully. Right. Right. And you know, we put it off on the BUCAs a lot, but providers can be, they're a lot of the problem. They're the ones that negotiate the high rates with the BUCAs. Yeah. And they can, they'll drop a BUCA off of their network, you know, and not let them in until they settle for a higher rate.
[00:12:25] So you've just got to, it's coming from all ends. We, I hope at one day at some point we have DPC all over. Yeah. And surgery centers that are not connected to these big conglomerates.