When we think of spring cleaning, we think of sweeping under the rugs, airing out the house, and washing windows. Doing these annual tasks not only helps us enjoy the warmer and sunnier weather, but it also helps clear out stale and musty air – which is good for our health.
You know what else is good for your health? A solid health insurance plan. If you are responsible for managing your company’s self-funded plan, spring is also the perfect time to check behind the curtains and shine a light on the corners of your plan.
Spring Cleaning Check List
Every year you should evaluate your self-funded healthcare plan. Your review should include the following:
- Benefit utilization. Are your employees using the benefits in the plan? Don’t pay for something with little value.
- Provider availability. Are employees able to access a large enough network of providers under any tier plan you offer?
- Cost. If your plan cost has increased substantially, examine why and see if there are alternatives. Are there a small number of employees driving costs higher for everyone? A separate plan may make more sense for them.
- Claims. A large part of the cost in your plan is obviously the payout of claims. We spend a lot of time talking about why you should have an annual comprehensive medical claims audit – and for good reason. If you don’t know where you are losing money, you can’t recover those lost dollars and you can’t fix the systemic issues. (Read a previous blog here.)
Finally, you should familiarize yourself with new government regulations and how that impacts you as a fiduciary. In 2023, this is even more important!
Plan for the Expiration of the Public Health Emergency
The ERISA legislation mandates that employers (or plan administrators) have fiduciary responsibility for the health coverage they provide for employees. The regulations and compliance requirements change often and “not knowing” isn’t an excuse for inadequate representation. One of the biggest compliance challenges over the past three years was implementing Covid-19 care. On May 11, the Public Health Emergency ended. This means that payer systems will need to be modified to change the paying structure for Covid testing and services, for COBRA extension enrollment that will be ending, and more.
Some key things to note:
- The declaration of the Public Health Emergency defined the period during which plans must pay for Covid-19 diagnostic tests and related services without cost-sharing, as well as other items.
- The National Emergency (which also ended on May 11) oversees dates and requirements for COBRA, special enrollment, and claims and appeals.
Oftentimes, charges for procedures due to end once health emergencies are lifted continue to be billed as a covered expense to plans, which means the plan and the self-funding entity overpay for services. Good auditors will find these overpayments in the data. Following are some of the more common provisions that sunset from plans 60 days after the end of the emergency:
- Covering Covid-19 tests without cost-sharing
- Over-the-counter Covid-19 testing
- Coverage of preventive services and vaccines in and out-of-network by non-grandfathered plans
- Expanded telehealth offerings to those not eligible for group health plan coverage
- Ability to waive certain wellness standards related to Covid
Hire Help to See Things More Clearly
Just like spring cleaning your home can be overwhelming, partnering with professionals can help – you can clean up your healthcare plan and shine a light on misappropriated funds and ensure that your plan has implemented all necessary changes with the end of the national health emergency. The best way to do this is with an annual medical claims audit. We are different because we work in partnership with you and speak with your TPA on your behalf.
Our audits are:
- Comprehensive. Settling for a random sampling audit guarantees you will miss finding claims errors. The error may be a $25 overpayment, or it may be $150,000. Are you willing to take that chance?
- Timesaving. You simply don’t have time to review all the data in your paid claims data set. Our process evaluates each claim and identifies those that are likely to contain errors. You can be as involved as you’d like in the process, but all we really need is a small amount of time upfront to coordinate plan documentation.
- Client-driven. Once we identify the claims that are agreed as overpayments, you choose the ones you’d like to pursue for recovery as some recoveries have member impact. Additionally, we offer customized, flexible pricing options designed to meet your needs and accommodate your TPA requirements. The return is more recovered dollars for your bottom line.
There’s never any time like the present to begin your spring cleaning, including reviewing audit rights, auditing paid claims and ensuring your plan is set up how you intended. We offer a complimentary review of your audit rights to ensure that you can review all your paid claims. After all, it’s your data!