Frequently Asked Questions

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We want our clients to feel comfortable with the audit process.  Below are some typical questions and answers for you to consider.  If these do not address all of your questions or concerns, please give us a call at 800-646-9987.  Relationships matter – it is personal to us.

Q: What is the cost for claims audit services?
Healthcare Horizons offers a risk-free pricing structure.  Our fees are based on a percentage of dollars recovered – not just errors identified.  We also offer fixed-fee or custom pricing options to accommodate your needs.

Q: What is the time commitment from the employer?
While we welcome involvement from our clients, set-up time is minimal.  We work behind the scenes so you can focus on your business.  After providing the basics, such as TPA contact information, plan documents, and funding amounts, your next step will be to review the report of audit findings.

Q: Will members be adversely impacted?
We will test areas such as benefit maximums and exclusions that could impact members if recovery is initiated, and we alert employers so they can make recovery decisions.  Healthcare Horizons does not bill any contingency fees for overpayments that employers do not wish to pursue. The goal is to correct issues for the future, resulting in long-term savings.

Q: Will an audit harm our relationship with our third-party administrator?
All of the national TPAs expect periodic audits as employers fulfill their fiduciary responsibilities.  Healthcare Horizons has built excellent working relationships with external audit coordinators across the country.  As auditors, we are thorough in our investigation, but we also know when to move on from an issue.  Our goal is to facilitate the best possible relationship with your TPA.

Q: What is the expected return?
It can be difficult to predict; however, the average return ranges from 1% to 3% of total medical spend.  We have had projects with much higher returns.  In addition to this immediate return, we often facilitate root-cause correction for future cost savings.  This can translate to significant amounts of money recovered in the short-term and even more savings in the long-term.

Q: What do we mean when we say two-year “no recovery trap?”
Most TPAs prohibit recovery of overpaid claims more than two years old due to provider contract limitations.  Ongoing annual audits ensure that all of your claims are eligible for review and correction.

Q: Will my employees’ protected health information (PHI) remain secure throughout this process?
Because data integrity and security are top priorities at Healthcare Horizons, we maintain extensive administrative, technical, and physical safeguards to protect the confidentiality, integrity, and accessibility of PHI consistent with the requirements of HIPAA Policies.  Our security provider, Sword and Shield Enterprise Security, Inc., performs an annual HIPAA Risk Analysis (HRA) and quarterly reviews to identify areas of risk associated with the storage, transmission, and processing of PHI.  Healthcare Horizons’ processes, controls, and policies are analyzed using the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) audit protocol.  Healthcare Horizons has been certified as HIPAA compliant.

Q: What are the next steps to pursue an audit with Healthcare Horizons?
The first step is understanding your current audit rights provided in your Administrative Services Agreement (ASA).  Healthcare Horizons can perform an informal, no-obligation review of your ASA to help you determine your rights.  From there, we will work with you to develop a customized audit proposal.