Q: What is the cost for claims audit services?
Our goal is to provide a risk-free fee structure for most clients. We base our fees on a percentage of dollars recovered (not just errors identified) on behalf of the employer group. Most clients prefer a risk-free contingency basis for auditing projects. We also offer a fixed-fee arrangement should the client prefer.
Q: What is the time commitment from the employer?
While we welcome involvement from our clients, the time commitment requirement is minimal. We will request information such as TPA contact information, plan documents, and funding amounts at the onset of the audit. The next significant involvement from the employer will be to review the report of audit findings.
Q: Will members be adversely impacted?
Healthcare Horizons will test areas such as benefit maximums and exclusions, that could impact members if recovery is initiated. However, we take special care to alert employers of these scenarios so that recovery decisions can be made. Most of our clients do not pursue recoveries that adversely impact current members. Healthcare Horizons does not bill any contingency fees for overpayments that employers do not wish to pursue. The goal is to correct these issues moving forward.
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 partner with TPAs to the greatest possible extent.
Q: What is the expected return?
The average return to our clients is approximately .5% to 1% of total medical spend. In addition to this immediate return, we are often able to facilitate root-cause correction for future cost savings. This often translates 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?”
It is likely that your TPA will only allow audits going back a maximum of two years. This is due to the fact that most healthcare provider contracts have language that prohibits recovery for payments over two years old. Ongoing annual audits will 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?
At Healthcare Horizons, protecting your members’ privacy and personal information is a top priority, as is guarding confidential company information in general. To that end, we have implemented 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) to identify areas of risk associated with the storage, transmission and processing of PHI. Sword and Shield analyzes Healthcare Horizons’ processes, controls, and policies against 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 is willing to perform an informal, no-obligation review of your ASA to help you determine your rights. From there, we’ll work with you to develop a customized audit proposal.