It’s fun to search for four-leaf clovers in the hopes of finding unexpected luck. But if you rely on wishes and leprechauns to keep self-funded healthcare expenses in check, your luck is going to run out.
Each year businesses lose millions of dollars from incorrectly paid medical claims. Even the best benefits administrators don’t always catch the mistakes – they don’t have the time to scrutinize millions of claims. Thankfully, there is a solution.
Healthcare claims audits analyze the paid claims data sets and look for overpaid dollars on medical claims. When incorrect payments are found, dollars can be recovered for a company. There are two kinds of audits: random sampling and comprehensive. Which do you think gives you the best “luck” in recovering the most dollars?
How Random Luck Can Cost You Money
Random sample audits are just that – completely random. Software generates the sample claims based on a dollar range. For example, if 250 claims can be reviewed during a site visit, the random selection process would involve five dollar range strata with 50 claims from each. Would you really want to select 50 claims in the $0 – $500 range when you may have overpaid claims in the million-dollar range? And what if the random generator doesn’t choose one of those million dollars claims that were paid in error? Your chances of recovering that money are only slightly better than finding a pot of gold!
Are you willing to hope and wish that all your errors have been identified through a random selection? With random sample audits, you are relying on luck that overpayments, including the largest errors, will be identified.
Comprehensive Healthcare Claims Audits Put Luck on Your Side
You can make your own luck by ensuring comprehensive claims audits are performed on your data. Opting for a comprehensive audit allows skilled individuals to inspect the entire data set, run hundreds of queries for likely errors and complete a site visit with claims that have been identified as a probable error.
Computer software may not discern anything unusual about a claim that paid a provider for five surgeries, on the same person and on the same day, but an experienced auditor will realize that the pattern is incorrect.
Finally, auditors work with the client to decide which claims to recover or in the case of member impact, negotiate a settlement with the TPA for the overpayment. TPAs will then recoup overpayments back to the client or issue a settlement to the client for the overpaid claims.
Your Self-Funded Plan Deserves More
Benefits managers are tasked with finding a health plan that is cost-effective for both the employer and its employees. Proactively negotiating the terms of the administrative services only agreement can protect the financial interests of both. In order to attain cost savings for the plan, a random sample approach is not optimal. We offer a complimentary review of your administrative agreement to make sure there isn’t language limiting your ability to audit healthcare claims and recover overpayments.
Take luck out of the equation. Insist on comprehensive audit rights and partner with a company that has expert auditors to recover the maximum dollars!
Attention SALGBA members! We’re going to be joining you at the conference in New Orleans next month! We’d love to become a trusted partner with you as you build alliances and identify resources to better administer benefits plans for employees. Stop by Booth 214 to learn about how we have recovered millions of Lost Benjamins for state and local governments.
