Podcast

heart care funding

Heart Care Funding is Not Just for February

woman holding healthy heart on shirt after preventative care exerciseFebruary is Heart Health Awareness month, but heart care should be a focus every month! Heart disease is the leading cause of death in America according to the Centers for Disease Control. Its impact is costly to all Americans and businesses and deserves appropriate funding.

 

Some quick facts:

  • Heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States.
  • One person dies every 34 seconds in the United States from cardiovascular disease.
  • About 697,000 people in the United States died from heart disease in 2020—that is 1 in every 5 deaths.
  • In the United States, someone has a heart attack every 40 seconds.

The financial impact is even more startling: heart disease cost the United States about $229 billion yearly from 2017 to 2018.

The consequence of this benefit not being available is not only a lack of quality heart care but also the possibility that good employees will leave for jobs that do provide healthcare benefits.

Finding Funds for Heart Care

Comprehensive heart care isn’t just treating acute incidents, like a heart attack, but includes cardiac therapies, medications and ongoing monitoring. Health insurance is a lifeline for millions of Americans suffering from heart disease. A substantial number of these individuals rely on their employers to provide coverage. Without this employee benefit, many people suffering from heart disease – or trying to prevent it – cannot get the comprehensive care they to protect their heart. For self-funded companies, healthcare is a substantial budget line-item.

What if your company could fund benefits without taxing the bottom line?

Ensuring that a healthcare plan is not overpaying for medical claims is one way to earmark funds for better heart and healthcare programs. There are two ways to avoid overpaying for heart-related medical claims: make sure they don’t happen in the first place and recover overpaid dollars if they do.

  1. Preventative Programs for Heart Care

Many programs are in place to help promote healthier living and mitigate the negative outcomes of heart disease. However, these programs – to be fully effective – have a cost associated with them. Yet, the costs of preventative care programs can be outweighed by the savings of not having to fund high-dollar, intensive treatments. For instance, having an annual fitness benefit in a health insurance plan encourages individuals to exercise more, which is good for the heart and can help prevent high blood pressure. Another example is implementing a regular wellness check requirement. These annual risk assessments, when completed, not only reduce premiums for employees but also discover any issues in the early stages, allowing for less expensive interventions to be used before major, more expensive, complications arise.

  1. Conduct Regular Comprehensive Audits to Recover Overpayments

Each year millions of dollars are overpaid on healthcare claims that are inaccurate. Consequences of these overpayments include:

  • Paying more toward plan maximums than required, and thereby reducing the number of claims that may be covered, if not in this plan year, then in the next
  • Increased administrative fees for self-funded employers, with the costs passed on to employees in the form of increased premiums or reduced benefits
  • Higher out-of-pocket costs for employees

Mistakes happen. In fact, up to one out of every three medical claim submissions has an error. It is the fiduciary responsibility of the entity providing health insurance (for self-funded companies, that’s YOU!) to ensure that the dollars spent are providing the services promised. Fortunately, human resources managers or employee benefits advisors have a powerful tool to help oversee this requirement: comprehensive claims audits. During a full audit, analysts review every claim for errors and assign red flags to those claims that seem illogical. These may be one-off mistakes (typically human input errors) or systemic errors that allow mistakes to repeat themselves, often snowballing and costing companies sometimes millions of dollars in overpayments. Having an annual comprehensive audit increases the likelihood of recovering these overpaid claims and correcting any systemic issues due to errors.

Not Overspending on Healthcare is Good for Everyone’s Heart.

Make a commitment to heart care this month and put in safeguards that will protect your company’s fiscal health and your employees’ health all year long. You can cover both ends of the saying, “An ounce of prevention is worth a pound of cure.” Work with health care insurance providers to implement preventative programs, but when you do have to fund bigger treatments, make sure you aren’t overpaying for the procedure!

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through our 100% Difference model and recovering millions of dollars for clients’ bottom lines while upholding the highest ethical standards. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for our customers.
shrm 22 banner

3 Things Benefits Managers Told Us at SHRM

clown on stilts at shrm conference for benefits managersThe SHRM conference in New Orleans this year was spectacular (ending the event with a Brad Paisley concert was icing on the cake!). It was wonderful talking with friends in the Human Resources world – in person – and meeting many benefits managers eager to find ways to contain costs in their employee benefits plans. In listening to these HR professionals, we learned three things:

  1. Most benefits managers think their brokers or TPAs handle all the auditing of their healthcare plans.
  2. Some were unaware that they should be reviewing audit rights in the ASO agreements.
  3. All worry about how much work it would be for them to do an audit and how much stress it would cause them.

Don’t Assume Your TPA is Looking Out for You

Your third-party administrator is tasked with one job: to process your medical claims in the most efficient manner. As benefits managers for self-funded employers, you trust your TPA to process the healthcare claims correctly so that you are not overfunding healthcare payments.

Unfortunately, even though so much of the process is automated, humans are still involved in the process. And humans make mistakes. Mistakes fall into one of two broad categories: one-off or systemic. (You can see a more detailed breakdown of the types of errors in our recent blog: Mistakes happen. Ignoring them could cost you.)

One-off errors are mistakes that, once fixed, shouldn’t happen again. These can include transposing a number in the claim code or misspelling a patient’s name. But just because these are “simple” mistakes, don’t think the financial hit can’t be significant! (Here is one example.)

Systemic errors are embedded issues within the claims process. These mistakes can cost a company hundreds of thousands of dollars over time. Typically, these errors occur because a mistake was made in setting up the plan. Examples include claims being filed through a location instead of a provider (as in this example) or a treatment being capped at a certain amount due to being categorized as out-of-network, when it actually is in-network.

The TPA has little incentive to look for these errors and recover overpaid monies.  Why – because they are paying with your money not theirs. While most TPAs are excellent at what they do and truly do want to process claims mistake-free, it’s impossible to do so at 100%. In fact, estimates show that up to 80% of claims data has an error. Not all of these errors have a financial impact, but many do. If your TPA, through your service agreement, is telling you they will perform an audit and that they guarantee a 98% success rate, you should ask for more details. Is the audit a random sample selection of claims for review? If so, it is highly likely they won’t randomly select the claim with the mistake. Are you willing to take that chance?

Your Company Does Not Have to Settle for the Standard Audit Language

In any negotiation, the first offer is probably not the best. The same is true for the audit rights language in most TPA service agreements. While the agreement says that you have audit protection, the language is typically very restrictive. For instance, does the agreement say that you cannot work with an outside audit firm? Make sure you are negotiating for comprehensive, independent audits. Not sure what to look for? Read this blog for tips. Additionally, we offer a no-cost audit language assessment to determine the effectiveness of the audit system in place for your company.

HealthCare Horizons Does the Work for Benefits Managers

HR professionals are busy. Our audit process involves you as much – or as little – as you want. Once you set the process in motion by giving us access to your medical claims data, we only need to involve you to decide which claims you would like to pursue for recovery. We provide clear communication on the impact the recovery will make (hint: it isn’t just the amount of dollars reimbursed!) and we will work with your TPA to move forward. If there is a systemic error, we will also explain in detail where the breakdown in the setup occurs so that your TPA can correct the problem.

As for stress? The only stress involved will be if you DON’T have regular comprehensive audits. Now that you know that there are most assuredly mistakes in your data set, the idea of losing money that could be returned to your company’s bottom line will cause sleepless nights.

The Only Bad Mistake is the One You Don’t Address

We say it often, not finding mistakes will do more long-term harm to your company, and potentially your credibility, than having an audit discover errors. Finding the claims errors and recovering dollars from overpaid medical claims means more money for your company’s bottom line. As the benefits manager, that is your responsibility. That money can go toward other valuable programs within your organization. Not to mention the money you save employees. Now you know. So now is the time. Contact us to start your medical claims audit. Cause the Effect.

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.