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Benefits Brokers Have Tools to Save Money

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Benefits brokers are trade professionals.

Just like any other profession, we count on them to provide expertise in addressing our problems. In healthcare, benefits brokers have tools that can save self-funded companies money on their health plans.

General Contractors for Health Insurance Plans

Think of benefits brokers as a general contractor for your self-funded health insurance plan. If you are renovating your home, you most likely will hire a general contractor to oversee the project. The contractor does not have all of the tools for a kitchen repair. Instead, they call a plumber to move water pipes, a flooring specialist recommends the best type of material for the traffic in your space, and an electrician makes sure all wiring is up to code. You want someone experienced in each area to make sure the project is done correctly and with the best return on investment.

Your self-funded insurance plan deserves the same treatment. A benefits broker has numerous tools to contain the costs of your plan, saving the company and employees money.

Benefits Brokers Tool: Claims Audits

One of these tools is a comprehensive claims audit. We partner with benefits consultants and brokers to provide this tool. Comprehensive claims audits discover and recover overpaid monies and identify systemic errors that can cost companies hundreds of thousands of dollars or more!

All audits are not created equal! What to look for in a healthcare claims audit process:

  1. Comprehensive Audits vs. Random Sampling. All healthcare claims data sets have errors. Do you really want to leave finding those errors to “chance?” That is exactly what a random sample audit does – eliminates the auditor expertise in finding errors – for a luck of the draw. Our comprehensive process ensures every claim is analyzed for potential error.
  2. Internal Audits. TPAs will sometimes perform limited internal audits for their self-insured clients. This is like the fox guarding the hen house! External audits are a best practice for satisfying the employer’s fiduciary responsibility.
  3. Realistic Time Frames. Many TPAs limit the number of times the plan can be audited as well as the length of the look back period for recovery on overpaid claims. Annual audits avoid the “too old to recover” claims.

Cause the Effect

For Human Resources leaders heading to the SHRM conference in June, you’ll recognize this phrase as the theme of the event. Incorporating audits into your overall healthcare plan is a direct action that leads to a positive effect. Ask your benefits broker if audits are included in the recommendations they are providing. If not, ask them to contact us. This is a must-have tool! Be sure to carefully review the audit rights in the administrative services only (ASO) agreement with your third-party administrator.  Have more questions? Stop by SHRM Booth #2870 and we can talk through your current situation and show you how we can help bring cost-savings to your company’s bottom line.

A Win-Win Tool

If, as a broker, you are not offering this tool to your clients, let’s talk! Providing audits is a win-win. Clients look to their benefits brokers and consultants to help save the company and their employees money. Company benefits coordinators and human resources leaders should be a bottom-line contributor for their companies! Make sure you are using every tool available to you to help them. As the health insurance professional, you are the general contractor in charge of the overall health plan for your client. Let’s partner to make you a winner!

For more details on how audits bring value to brokers and their clients, read “4 Claim Audit Benefits for Self-Insured Clients.”

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, involving all national and most regional payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.
Businessman putting a card with text ADD VALUE TO YOUR CUSTOMERS in the pocket

Brokers: 4 Claim Audit Benefits for Self-Insured Clients

Providing Value-Add to Clients

Claim audit service is an extra benefit for brokers to present to clients. Audit services can save clients big money over time. There are 4 significant advantages to brokers who include a claim audit service in their proposed recommendations.

  1. Healthcare is the largest expense for self-insured employers. They should feel confident that their money is being spent correctly. A broker is held to a high standard by clients to provide the best cost-saving options for their employee plan. Audits ensure that the TPA is held to the same standard.
  2. When audits save clients money, they are more likely to be repeat customers. Potential new clients will then want to know what methods are being used to contain costs and keep premiums in check.
  3. Audits can identify systemic problems with claim processing. If problems are uncovered and not corrected, the broker has the opportunity to suggest different services and vendors.
  4. Analyzing audit findings can reveal trends that allow improvement to RFP questionnaires. Thoughtful RFPs then allow the broker to make the best recommendations for healthcare plans.

Healthcare Horizons’ claim audits are guaranteed to impact at least one, and probably all four, of the benefits listed above. We analyze every claim, not just a small sample of claims, and work with clients to make recommendations for cost-savings opportunities they may be missing in their plan set-up. We not only identify overpaid claims that can be recovered but also discover potential systemic problems that lead to overpayment trends. Recommending claim audit options to your client is a win-win for you and them.

Limiting Audits

August is an important month for TPA negotiations. As brokers move forward to find the best third-party administrator for their self-insured clients, they must be aware of language in the services agreements that may limit the client’s rights to audit claims and recover overpayments.

A hurdle in many new administrative service agreements is a restriction limiting the ability of self-insured clients to have an audit of all claims in their data set.

Why is it important for audits to be freely accessible by self-fund clients?

  • While TPAs will commit to some form of internal auditing, they restrict external auditors from conducting comprehensive auditing. This is a conflict of interest. Outside auditors are unbiased and can be used whenever a client feels it’s necessary.
  • Few TPAs will conduct internal audits as a part of the contract. Usually, there is an additional cost to perform the audit. Depending on payment structure, outside auditors can perform contingency-based audits where the self-insured client only pays fees after an overpaid claim is recovered.
  • Audits conducted on a yearly basis avoid the possibility of claims being unrecoverable. A common eighteen-month to two-year limitation on claim recovery is written in many TPA agreements.

Healthcare Horizons offers a free review of administrative service agreements to ensure that a client’s rights to audits are protected.

five benefits of brokers working with healthcare horizons on claim audit
If you are a broker, stop by SHRM Booth 5079 or contact us directly to talk about the different ways we can help make you a savings hero in your client’s eyes!

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Best ROI for Four Hours Work
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com. 
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.