Our Approach

Healthcare Horizons offers a unique approach to healthcare auditing, one that yields more comprehensive results than the standard random-sample audit offered by most healthcare audit firms, resulting in the greatest possible savings for our clients. We refer to this approach as the 100% Difference, and with it we have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers across the country.

WHAT IS THE 100% DIFFERENCE?

The typical outdated methodology for claims auditing is by random sample, whereby auditors randomly select approximately 200-300 claims out of millions of transactions, examine those claims for errors based on predetermined criteria, and extrapolate the results across the entire range of claims. While this approach may be considered standard practice when handling so many claims, it also carries a margin of error that can work against the company. For example:

  • If the auditor encounters an error on a selected sample claim, it is virtually impossible to determine if the error is isolated or systemic in nature.
  • It is likely that significant one-off errors exist outside of the random sample selection.
  • It is often difficult to convince payers to issue settlements based on the results of a random-sample audit.

By utilizing our proprietary set of algorithms applied to an electronic file of all paid medical claims, we conduct the audit on all claims, rather than a random selection. This approach yields much better results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, making a much stronger case to the payer. As a result, employers can recover significantly more in overpayments than random sampling allows. Additionally, our clients can correct systemic issues, preventing future claims paid in error.

BENEFITS TO YOUR COMPANY

We help your Human Resources department become a bottom-line contributor.

  • People/Relationships First: You are in charge. You determine which claims to recover. You decide how hands-on you want to be.
  • High yield for little time investment: Minimal time is required by the client to set up the audit, which can pay off greatly in return on investment. If hindsight is 20/20, we give you perfect vision, leading to future savings.
  • Streamlined process: We work behind the scenes so you can focus on your company’s ongoing operations and productivity.
  • Clear and Simple Communication: We keep you informed and up-to-date on the process. We take special care to alert you so recovery decisions are made with an understanding of member impact.
  • TPA Relationships Respected: We work with your TPA to identify errors, monitor collections, and help negotiate with the TPA for direct credit or settlements.
  • Satisfies fiduciary responsibility: Performing an annual healthcare claims audit and recovering overpayments, not only can improve the client’s bottom line, it satisfies part of the fiduciary responsibility to plan members and stakeholders. Performing an annual healthcare claims audit improves your bottom line and avoids the two-year ‘no recovery’ trap.

Of course, Healthcare Horizons can perform random sample audits for our clients who request it or are contractually obligated to do so, but the companies that take advantage of our 100% approach typically see a significant increase in overpayment recovery on claims as compared to the random sample approach. To learn more about how our 100% Difference can save your company money in the long run, talk with one of our experienced representatives today.