The typical (and sometimes contractually required) methodology for healthcare claims auditing features auditors randomly selecting 200 to 300 claims out of millions of transactions. They examine those claims for errors based on predetermined criteria and extrapolate the results across the entire population of claims. This approach may be considered standard practice by your TPA when handling so many claims, but is an outdated and ineffective approach. (It is important to know your audit rights BEFORE you sign a contract with a TPA!)
Does a random sample audit take your financial best interests into account? Some things to consider:
- If the auditor encounters an error on a selected sample claim, it is virtually impossible to determine if the error is isolated or systemic in nature.
- It is highly likely that significant one-off errors exist outside of the random sample selection.
- It is often difficult to convince payers to issue settlements based on the results of a random-sample audit.
Healthcare Horizons’ comprehensive audits review every healthcare claim, rather than a random selection. Our approach, called the 100% Difference, yields much better results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, making a stronger case to the payer. As a result, employers can recover significantly more in overpayments than random sampling allows. Additionally, our clients can correct systemic issues, preventing future claims paid in error, saving their companies thousands (or millions!) of dollars over time.
Check out this short video, which visually demonstrates how a random sample audit works and how it could potentially cost your company thousands of dollars.
It’s YOUR money. What will you do with it?
The 100% Difference: Every Claim. Every Possible Dollar.
Visit Healthcare Horizons today to learn more, or contact us at hhadmin@healthcarehorizons.com to discuss a healthcare claims audit assessment.
Randy King is president of Healthcare Horizons Consulting Group, Inc., which has performed healthcare claims audits since 1999. Trusted partner. Uncompromising accuracy. Superior personal service. Recovering millions of dollars for some of the world’s largest employers.