We know comprehensive medical claims audits are the best way to protect your company’s self-funded health insurance investment. We also know that the claims audit process can seem intimidating. But it doesn’t have to be! Here are some of the most common questions we are asked. We would love to talk with you about claims audits and how we can help you return overpaid dollars to your bottom line.
1. What type of medical claims audit should we choose?
You have two options for audits: random sample and comprehensive (also called Targeted or Focused). We perform comprehensive audits, where 100% of your claims data is analyzed, because we know that random sample audit findings are the luck of the draw. Unfortunately, your administrative services only agreement (ASO) may limit you to random sample audits. Random-sample audits are better than not performing an audit at all; however, random-sample audits can leave thousands of dollars behind. We can help you evaluate your audit rights at no charge to make sure you have access to the most effective audit available.
2. How much does a comprehensive audit cost?
Our customized, flexible pricing options are designed to meet your needs and accommodate your TPA requirements. Our fixed-fee pricing ensures you know exactly what your out-the-door audit cost will be and is most often covered by the recovered dollars. We also offer a risk-free, contingency pricing structure that is based on what we collect, not on the errors we identify.
3. How much money can I expect to have returned from each audit?
It is difficult to estimate a rate of recovery, but on average .5%-1% of the total annual medical spend is returned. Recovery amounts depend on several factors including:
- The amount of the overall claim
- The number of claims an ASO allows to be analyzed
- The age of the claim (most ASOs won’t allow recoveries of claims older than 12-18 months, which means annual audits are a must!)
4. How much time do I need to set aside for the audit?
While we welcome any involvement in the audit process from our clients, the time commitment of the client is minimal. The client must review and sign the contract and Business Associate Agreement, provide plan documents and once the audit is complete – review the audit report. Below is helpful information a client can provide to enable us to ensure the best pricing.
- Client Name
- The Third-party administrator (TPA) processing claims
- Total annual medical spend
- How many subscribers/members on the plan
- Number of plan designs offered (HDHP, PPO, etc)
- Audit rights (Comprehensive 100% audits rights versus random sample selection; fixed fee pricing versus contingency pricing)
5. What communication can I expect during the audit process?
We will send updates to your company’s point of contact throughout the audit process. These check-ins include:
- Proposal that outlines our audit process, categories of testing, and projected cost
- Preliminary findings of the initial review
- Final audit report that includes dollars associated with recoveries, our final audit comments in response to the TPA, and recommendations on best practices
- Any post-audit communications we receive from the TPA on the recovery process
There is no time limit on our availability post-audit. We are happy to answer any questions.
6. How long does an audit take?
Audits typically take 4-6 months to complete. The length of an audit is largely dependent upon receipt of viable data, the TPA timeline for preparation of the audit and scheduling the virtual site visit. (POTENTIALLY INSERT TIMELINE GRAPHIC – YES that would be good here)
7. Are there any performance guarantees?
We do not offer performance guarantees, which often do not represent true success. Our commitment to our clients is to continually look for ways to do what we do better. Accuracy is important in our business. We are constantly refining our data mining process to find every error possible to yield higher recuperations for our clients. We believe that our long-standing relationship with numerous clients is a testament to our performance and accountability.
8. What experience does Healthcare Horizons have in our industry?
Healthcare Horizons has been exclusively performing healthcare claims audits for self-insured employers for the past 24 years. We perform audits for companies in a multitude of industries, but our process remains the same no matter the industry of our clients. This breadth of experience across many different employers, industries, and claims administrators allows us to bring industry best practices to each project. It also provides us with the benefit of having seen almost every benefit setup, provider contract method, and claims administration policy that one would expect on a claims audit.
9. How do you work with our TPA? Will performing an audit negatively impact our TPA relationship?
Third-party administrators are partners in helping recover as many overpaid dollars as possible. The TPA works with Healthcare Horizons to provide the medical claims data set, provide necessary reports surrounding the targeted sample selection and engages in dialogue concerning findings. Since audits should be an included provision in an ASO, the TPA expects that you will uphold your fiduciary responsibility to ensure the best management of your health insurance plan investment.
10. How do you ensure privacy and compliance mandates are met?
While sponsors of non-Federal government health plans may elect to exclude certain categories or plans for privacy reasons, doing so can impact findings and monetary returns. We understand that data integrity and security are top priorities and so we maintain exceptional administrative, technical, and physical safeguards to protect the confidentiality, integrity, and accessibility of protected health information consistent with the requirements of HIPAA policies.
Don’t let unanswered questions halt your medical claims audit.
Medical claims audits are valuable resources to protect one of the biggest expenses in your business. We are happy to review the audit rights language in your administrative services agreement at no charge to help determine the correct audit approach for your company, as well as make suggestions for future negotiations with your TPA. Don’t pay more in claims than you are required to pay! Get your questions answered and start the audit process today!
Are you going to be at SHRM 2024? Call us at 800-646-9987 to schedule a meeting or visit us at booth 1557 to ask your audit questions and enter to win a unique prize!
