Self-insured employers cap catastrophic risk with stop-loss and out-of-pocket maximums, but 95% of healthcare spend happens before anyone hits a cap. That's the unmanaged middle, where unit-price variance, template billing patterns, and unexplained cost dispersion go undetected. Drawing from 17 years of building claims analytics for health plans, ACOs, and TPAs, and processing data for millions of lives, this session uses real claims data to expose the fiduciary gap between what ERISA requires and what most organizations actually oversee. Key takeaways: - Why brokers and TPAs each do their job well - but a third function (fiduciary audit) doesn't exist in most organizations - How to read claims data at the unit-price level and spot unexplainable variance (real example: 21x price difference, same CPT, same network, same region) - What "reasonable" oversight looks like as a continuous governance function, not a one-time audit - Your rights and obligations under ERISA §404(a)(1) and CAA 2021, and what you'd produce if the DOL asked tomorrow - How fiduciary intervention compresses outlier billing without dropping providers