What Medical Claims Audits Find
First, and most importantly, comprehensive medical claims audits WILL find overpaid dollars in healthcare claims. Is that all you need to know? Great! Click here to contact our office to schedule a consultation
But wait, there IS more! Reviewing all claims in comprehensive audits is only one way we identify potential cost savings errors in self-funded healthcare plans.
In the constantly changing healthcare environment, periodic audits are essential to help identify and correct patterns of overpayment. At Healthcare Horizons, we are committed to thoroughly reviewing all available data to ensure that our clients’ fiduciary obligations regarding healthcare payments are being met as accurately as possible. This results not only in the recovery of overpayments but also in the correction of root-cause issues to improve efficiency and generate long-term savings for our clients.
Based on this thorough review of data, we make recommendations to our clients after each audit to help contain costs going forward and protect their bottom line.
Three Common Audit Recommendations by Healthcare Horizons
1) Clients should consider negotiating enhanced audit rights in future administrative services agreements.
Healthcare Horizons always recommends that clients explore options for a more comprehensive, targeted audit of all future claims if the audits are currently limited in scope by their Administrative Services Only (ASO) agreements. If the ASO only allows for random sample audits, the chance of finding errors drops significantly. (Read this blog about the importance of equal fiscal protection for your company.)
2) Clients and their TPAs should agree upfront on how out-of-network charges will be handled.
Too often we see claims processed according to what the TPA believes the plan defines but catches the clients (and usually the employee) by surprise with an unexpected out-of-pocket payout. We recommend two key inclusions: a set agreement for the maximum allowed amount that will be paid on out-of-network claims and the ability to consider pricing options other than full-bill charges. A maximum limitation sometimes found in agreements is to cap the out-of-network payments at 125% of the Medicare amount. Healthcare Horizons also helps with out-of-network charge negotiations, specifically in helping to identify fair pricing strategies.
3) The Client and TPA should discuss plan intent for situations in which other primary coverage should pay as primary.
This occurs frequently with employees that are also eligible for Medicare. Once an employee or a former employee under COBRA turns 65, Medicare should provide the primary coverage for them. If the employer plan is secondary to Medicare under federal law, the plan will not pay benefits for services or supplies that are included within the scope of Medicare’s coverage. This occurs even if an employee fails to enroll in Medicare when eligible. In other words, if a participant is eligible for Medicare Part B benefits but does not enroll, the plan should pay as if the participant had enrolled in Medicare Part B. The plan would then pay any secondary coverage after the Medicare Part B estimation.
The ASO needs to include language that addresses Medicare Part B estimation requirements. This outlines how the TPA estimates what Medicare should pay for a particular claim. Then the TPA factors that estimate into determining what the employer plan will pay on the claim.
Medical Claims Audits Protect the Company
Not having medical claims audits as an annual must-do is like not reviewing your insurance coverage for five years or not balancing your checkbook (we think that is still a thing!). Only by having a full, comprehensive look at all medical claims are you able to determine if there has been an overpayment, misinterpretation of benefits, fraud and abuse, or systemic errors causing up to thousands of dollars of repeated Lost Benjamins. Self-Insured plan fiduciaries are responsible for making sure the healthcare plan is administered properly. Any errors or unexpected bills are the COMPANY’S responsibility to pay and sometimes fall to the employee. The good news is that you don’t have to leave that to chance. Let’s talk about what medical claims audits can find for you!
_______________________________________________________________________________