According to BenefitsPro, best-in-class employers manage benefits differently from their peers. For one, they are more likely to self-insure their benefits, despite the greater financial risk. Why? Because they want the ability to manage their own plans and lower their health care costs through better plan management. However, if they fail to annually audit 100% of their claims to root out errors and overpayments, they are not receiving the full benefit of self-insuring.
Unfortunately, TPAs do not have the financial incentive to ensure that claims are paid with 100% accuracy, but self-insured employers do, with overpaid claims recoveries returned directly to their bottom lines. Brokers, acting in the best interests of their clients, can help their clients meet their fiduciary responsibilities, while recovering the most money possible. By offering the full advantage of today’s newest auditing technology and years of experience, Healthcare Horizons performs comprehensive audits instead of outdated random sample audits — at no extra cost or time commitment from the client.
Brokers also can negotiate full audit rights for their clients for maximum savings. Allowing TPAs to dictate audit rights by requiring ineffective random sample audits does not meet the standards of reasonable expectations. Self-insured groups should not be restricted from looking at all paid claims.
We often hear benefits partners mention that they are looking at high dollar claims as part of their process but reviewing high dollar claims alone will not uncover systemic issues. For example, in the following case study, a review of high dollar claims would not have uncovered a serious systemic error that was costing our client thousands and thousands of dollars every year.
Case Study
By rule, Medicare is generally primary coverage for COBRA participants who are age 65 and older. In other words, employers only have secondary liability for healthcare claims. A comprehensive audit for our client revealed that a large volume of claims were incorrectly paid as primary. As it turned out, the TPA was relying solely on Coordination of Benefits (COB) questionnaires to determine the existence of other primary coverages. As you can imagine, the response rate on the questionnaires was very low. Based on our findings, the TPA now automatically contacts Medicare to determine applicable coverage for all members on COBRA who are age 65 and older. In addition to root-cause correction for any future overpayments, we were able to identify more than $1 million in recoveries for our client.
Healthcare Horizons reviews 100% of claims paid. That is our 100% Difference.
To learn more about our approach to healthcare claims auditing, visit Healthcare Horizons or contact us at hhadmin@healthcarehorizons.com to discuss a free audit rights assessment.
Visit us at the SHRM Annual Conference and Exposition in Las Vegas, June 23-26, 2019, at Booth 3317 and learn how the 100% Difference can help self-insured employers control healthcare costs. Draw for a chance to win big, and don’t get left holding the bag!
Randy King is president of Healthcare Horizons Consulting Group, Inc. Performing healthcare claims audits since 1999. Trusted partner. Uncompromising accuracy. Superior personal service. Recovering millions of dollars for some of the world’s largest employers.