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right tools put money in bank

Benefits Brokers Have Tools to Save Money

filled tool box benefits brokers

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.

The Biggest Mistake in Healthcare Agreement Negotiations

Each year, companies – and their employee benefits manager or health insurance broker – hold negotiations with third-party administrators (TPAs) to handle the details of self-funded healthcare plans. These agreements can directly impact a company’s bottom line.

Considering the rising cost of healthcare and incidences of significant overpayments of claims, including fraudulent or abusive claims, ensuring the plan addresses its fiduciary responsibilities is very important. If you are currently in the important “negotiations season,” be sure your self-funded healthcare plan is fully protected.

Did You Know?

You don’t have to accept the standard audit language in a proposed TPA agreement. It is an ERISA fiduciary responsibility of human resource managers or benefits consultants/brokers working on behalf of their plan to ensure that the language included in a services agreement is beneficial to everyone, but most importantly to the company.

The Most Common Mistake in Negotiations

Most TPAs will tell clients that they do in fact have audit rights within their agreements. However, in too many cases, the language is very restrictive and doesn’t really protect the company. Not negotiating for full audit rights is a HUGE mistake!

Full audit rights include these key components:

  • Comprehensive claims review, not just random sampling
  • Non-restrictive targeted sample size
  • Minimum of two-year period for recovery of overpayments
  • Fee structure based on recovery, not fixed

Random Sample vs. Comprehensive Audits

Random sample audits are usually listed as the allowed audit type the standard audit found in
most TPA agreements. Sometimes TPAs do not allow any type of audit. The biggest downside to random sample audits is that they, obviously, do not allow for a full review of all the data. When only a randomly selected portion of a data set is analyzed, it is nearly impossible to identify any patterns of abusive billing or systemic issues.

While benefits consultants claim they are performing audits and don’t need an external audit company, most of these audits only consist of

  • high dollar claims,
  • eligibility reviews, or
  • obvious fraudulent charges.

Here is one example of how a random sample audit works.

  • Auditors randomly select approximately 200-300 claims out of millions of transactions.
  • Auditors examine those claims for errors based on predetermined criteria.
  • Auditors extrapolate the results across the entire range of millions of claims to determine a claims error percentage of the entire population.
This approach carries a high margin of error that can work against the company. The fallout from the random sample approach is significant.
  1. If the auditor encounters an error on a randomly selected sample claim, it is virtually impossible to determine if the error is isolated or systemic in nature.
  2. It is likely that significant one-off errors exist outside of the random sample selection.
  3. It is often difficult to convince payers to issue settlements based on the results of a random-sample audit.

Random sample audits may leave undiscovered mistakes, and therefore money, on the table. This penalizes not only the company but the employees as well.

Conversely, a comprehensive audit starts with a review of the entire data set and an identification of known trouble areas. Audit companies with decades of experience can see red flags in data sets and start reviews at this point. Then, the comprehensive audit can pinpoint isolated and systemic errors in the audit process. Actual dollar amounts are assigned to these mistakes, making it very easy for payers to see where reimbursement is owed. As a result, employers can recover significantly more in overpayments and can correct root causes of the issues, which will prevent future claims from being paid in error.

Demand Comprehensive Audits Rights During Negotiations

There are numerous misconceptions about working with an outside auditing firm. The most common is that many TPAs believe working with a company like Healthcare Horizons will penalize them. At Healthcare Horizons, we work WITH a TPA to ensure errors are found and corrected. The TPA has the interest to see that their client is protected.

During the next negotiations cycle, HR departments, benefits consultants/brokers, and TPAs need to work together to demand accountability in healthcare claims and protect the financial interest of the client.

Use this checklist to make sure you have comprehensive audits rights in your TPA agreement. It’s YOUR money and your fiduciary responsibility to make sure that your medical plan is being administered appropriately.

negotiations checklist

Healthcare Horizons offers a free assessment of administrative service agreements to determine the proper inclusion of audit rights. Contact us so we can help you manage your fiduciary responsibility as it pertains to your company’s self-funded healthcare plan.

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.

No Surprises Act Impacts Businesses

Don’t Let the No Surprises Act Catch You Off Guard!

By now, anyone providing healthcare plans as an employee benefit should be aware of the new No Surprises Act, effective at the beginning of 2022. Whether you are the human resources manager tasked with outsourcing this important benefit or the health insurance broker providing options to companies for coverage, the new law has several components that must now be met and coordinated through plan sponsors.

The good news is that the No Surprises Act adds more transparency and accountability – all designed to protect the consumer. However, what is coming as a surprise to many companies that self-fund their employer healthcare plan, is that the employer is the one responsible for all compliance.

What are the key provisions of the No Surprises Act?

No Surprises Act protects patients and members from surprise or hidden fees
The No Surprises Act mandates that providers and healthcare plan administrators post cost information to members in a clear and timely manner.

Increased transparency is the overarching intent of this new law. Designed to make healthcare costs easier to understand, providers and plan administrators must provide more information to members than ever before. Examples include:

  • Providing timely good faith estimates of costs
  • Clearly outlining the explanation of benefits once charges have been submitted by the provider
  • Offering cost comparison tools easily accessible by the member

How are self-insured employers impacted by the No Surprises Act?

Employers must be aware that their members cannot be balanced billed (Balance billing) for emergency services, non-emergent services from out-of-network providers provided at in-network facilities, and out-of-network air ambulance services. Patients will only be responsible for paying their in-network cost-sharing. If there is a difference in the cost of service, once all applicable deductibles or co-pays have been met, the employer is responsible for working with the provider to cover the remainder of the bill. The provider and the plan administrator have set guidelines for negotiating the final payment.

What steps should self-insured employers take to protect their bottom line?

It is likely the No Surprises Act will increase plan costs through both claims and IDR (independent dispute resolution) fees. Additionally, insurers will ask for increased administrative fees to provide services required by the law. But there are two important steps employers can take to minimize the financial impact.

  1. Self-insured employers should ascertain from their third-party administrator (TPA) how the QPA (Qualified Payment Amount) will be calculated. While compliance is the responsibility of the employers, most payments will be made by the TPA. The QPA is a newly created term in the act and is the plan’s median contracted rate — the middle amount in an ascending or descending list of contracted rates. If an employer doesn’t know what that QPA amount is, predicting costs is much more difficult.
  2. Employers should fulfill their fiduciary responsibility and request comprehensive external audits of their medical plans to make sure their TPA is processing claims correctly. Unfortunately, many TPAs restrict audit rights to a random sample selection of paid claims that can be reviewed. And many self-insured groups aren’t auditing their paid claims at all. Auditing medical claims is an industry best practice and should be standard practice for self-insured employers.

Having a plan provides peace of mind.

A thought-out plan for implementing the requirements of the act should be in place for any company that provides a healthcare benefit to employees. Plan sponsors should review the new requirements of the No Surprises Act with consultants, service providers, and legal counsel. The plan should detail who will be responsible for monitoring the impact of the new law. One of the key components that should be included in a plan is regular, comprehensive audits. Audits not only find and recover overpayments but also identify systemic issues within the payment process. Mistakes happen, but they are even more likely to occur when new policies and procedures are put in place. Finding the mistakes early helps contain costs for both the employer and the employee.

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.
20220outlook for healthcare trends

2022 Healthcare Benefit Outlook

It’s that time of year. Time for the annual reflections on the past year and predictions for the next. While you might think there isn’t much change when it comes to employee benefits and healthcare trends, the past two years have proven to be full of surprises. So, we’ll look at the highlights from 2021 and then explore what we see as the 2022 healthcare benefit outlook.

Healthcare benefits outlook for 2022

The Impact of the Pandemic

2021 highlighted the negative impact of the Covid-19 pandemic in the workplace. Employers had to analyze nearly every aspect of their work culture, and that included employee wellness. Out of these reviews, clear trends emerged. Women experience more burnout than their male counterparts.  Mental health issues were up across the board as people struggled with work and home worries. Remote work exploded, adding new issues for human resources, cybersecurity teams, and the home-work balance. However, as the saying goes, necessity is the mother of invention. (1)

The Healthcare Benefit Outlook

According to new research by LinkedIn, the top three things Americans value most in their career now are work-life balance (34%), compensation (32%) and benefits (26%).

When you hear ‘employee benefits,’ the first two things that jump to mind are probably paid leave and healthcare coverage. With the Covid-19 pandemic stretching into year two, these are still the top “wants” from employees. However, we’re also seeing companies offer a larger variety of perks and solutions to attract and retain strong teams.

Some of these non-traditional benefits include hybrid work options, mental health benefits, more personal time off (with less stipulation for how the time can be used), and financial planning assistance. Yet, the biggest changes are likely to be seen in how healthcare is provided and funded.

Healthcare Benefit Coverage

At its core, the pandemic was a health care crisis. The panic and uncertainty that evolved from sickness, fear, or loss of income emphasize the importance of investing in comprehensive healthcare benefits for employees. Insurance brokers and human resource benefit managers need to keep this insecurity in mind as future benefits are structured.

Flexibility is Key

Gone are the days of one-size-fits-all plans. More personalized healthcare coverage is expected to grow over the next year. Employees realize they may need, or want, different levels of care than their co-workers. This is not surprising when almost every area of our lives, from how we stream television to our GPS, is customized. The areas listed should be explored to provide the best comprehensive coverage for individuals and families. (2)

  1. Personalized coverage. Each insured member should be able to choose the best care and price-point for their needs. This is actually a win-win for employees and employers. For example, when set up from the onset, people who first use lower-cost interventions see lower prices, if or when their care escalates. This rewards high-value care decisions that can make employee populations healthier in the long run.
  2. Personalized cost-sharing. Most employers provide an equal level of coverage for all employees. But that approach isn’t personalized. In fact, it can contribute to coverage inequity and perpetuate health care disparities. For example, consider two employees who have a $3,000 deductible on their employer-sponsored health plan, receive the same subsidy from their employer, and are eligible for the same level of coverage. To many, this sounds fair, but if one of them earns $30,000 a year and the other earns $300,000, their ability to access coverage is very different—and that is inequitable.
  3. Personalized experience. We can’t forget about opportunities to personalize care navigation and support experiences. People want to feel seen and heard. It’s important that employees have access to a broad network of high-quality, low-cost providers who speak their language, understand their culture, sexual orientation, gender identity, etc.—and they need help finding these providers.

Healthcare Benefit Outlook Incentivizes Utilization

Data shows 15% of Americans with employer-sponsored health insurance deferred some care between March and September 2020.

This statistic foreshadows both short and long-term implications for not prioritizing preventative care, which catches small health concerns before they become costly more serious issues.

“For years, we’ve used deductibles and copays to manage utilization and minimize cost increases in the hope that individuals would become better educated and make better health care decisions with some financial skin in the game. However, even before the pandemic, it was becoming clear that this didn’t work, but rather caused employees to defer and even skip preventative care altogether. And now, as preventative care utilization tanked during the pandemic, employers will increasingly see the costly, long-term effects of offering plans that don’t incentivize receiving care early and often.” (3)

Employees need to know their options and be able to access the care they need, when and where they need it. This will improve health, reduce high-cost claims, provide a return on the investment of the resources and costs, and deliver a health program with value for all employees.

What Does This Mean for HR & Insurance Brokers?

The status quo is changing. It’s not what it was 3 years ago and it likely won’t be the same at the end of 2022. First, it’s up to you to provide employee healthcare benefit options to clients that meet the needs of both employee and employer. You can achieve these goals during enrollment season:

  • Find plans that remove barriers to employees accessing care
  • Ensure the plans offered have uncomplicated user experiences so that confusion does not become a deterrent to use

Second, since we all know that prices aren’t likely to come back down – especially in healthcare – identifying cost savings for benefits is imperative.

Finding cost savings to provide exceptional benefits

We want to help you provide the best overall employee benefits in 2022 and beyond. Addressing overpayments in one of your largest budget line items is a great first step. But you first must know what your data says. Then you can look for ways to reduce overpaying on healthcare claims. Dollars can then be reallocated toward other company initiatives or help keep healthcare costs from rising.

Our “every claim” audits find the errors in data sets – and they are there! Some may be one-time mistakes, but others may be systemic issues causing repeated overpayment and loss of dollars. We are experienced in identifying both.

It is also important that your medical claims are being processed according to your plan design and intent. In our audits, we review your claims according to the unique benefits detailed in your medical plans to ensure those benefits are being administered correctly.  If not, these types of processing errors could continue to reoccur and add up to significant overpayments.

2022 will be full of challenges with new legislation for transparency and rising costs. However, we saw perseverance and out-of-the-box thinking this past year that gives us hope in regard to the healthcare benefit outlook. We would welcome the opportunity to partner with you in providing a cost-efficient experience for your company or clients.

Sources:
(1) https://www.benefitspro.com/2021/12/07/progress-report-how-far-have-employee-benefits-come-in-2021/
(2) https://www.benefitspro.com/2021/11/16/personalized-health-benefits-are-the-future/
(3) https://www.benefitspro.com/2021/11/16/3-benefits-trends-to-consider-for-a-post-pandemic-workforce/
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.
Analyzing healthcare budgets and finding errors with audits

Budgets and Healthcare Audits: A Smart Partnership

When you are preparing a company budget, are you including healthcare audits? Budgets and healthcare audits are both necessary pieces for fiduciary responsibility. Failure to audit could be a red flag that you haven’t protected the financial interests of your employees & employer.

budget and audits present money as gift
Healthcare audits return YOUR money back to your budget.

What’s at stake?

    • Employers pay an average of 86% of healthcare premiums for single coverage and 72% for family coverage.
    • Health insurance costs approximately $2.64 per hour for private industry workers.
    • In 2020, the average annual premiums for employer-sponsored (self-insured) health insurance were $7,470 for individual plans and $21,342 for family coverage.

Source: SanaBenefits

Obviously, this is a significant portion of a company’s budget. Healthcare costs are expected to continue to rise, so company leaders must find cost savings while still providing competitive, quality care for their employees.

Protecting Employer and Employee

Simply, healthcare claims audits find errors. And if your company is providing healthcare, there are errors in your claims. Your healthcare budget, and your employees’ healthcare expenses, can be contained with regular audits.

In a successful comprehensive audit, you will recover overpayments and identify potential systemic issues causing the incorrect billing. Both are important.

Overpayment of Healthcare Claims

Recovering funds is the most important step for both employer and employee. If claims are overpaid, the employer will see more expenditures in individual claims, but also potentially be quoted for higher premiums at the next negotiation period.

For employees, claim overpayments can negatively impact employees’ deductibles and co-insurance payments. Look at the following example.

An employee had gall bladder surgery in an in-network surgery center. A primary and an assistant surgeon performed the surgery. Assistant surgeons are generally priced at 20% of the full schedule rate. However, this assistant surgeon was out-of-network and billed more than $20,000 for the surgery. Since the assistant surgeon was paid at full billed charges, the patient ended up paying more for their co-insurance than they would have paid if the assistant surgeon had been paid according to the applicable fee schedule. The employee did not have any other medical claims for the year, but unfortunately still reached their out-of-pocket maximum due to this claim processing error and was out more than $3,800.

Systemic Errors in Healthcare Billing

Systemic errors are different than data entry errors. With systemic errors, there is a process in place that is causing repeated errors in billing. Eliminating these root cause problems should reduce the number of claim errors you have in the future.

For example:

A facility may be unbundling charges that are meant to be billed as one item. Unbundling is when providers charge for line items individually instead of using a code that bundles charges. By unbundling the provider gets paid more than they should had the correct bundled code been used.

Have you met your fiduciary responsibilities by including audits in your company budget?

If the answer is no, contact us. “Health plans have a fiduciary responsibility to their members to make certain that the members’ claims are processed and paid correctly,” says Barry Silver, Healthcare Horizons Senior Vice President. “Otherwise, their employees could end up paying more money than they should on medical bills. The plans can engage external auditors to review the medical claims payments to assess if their claims process is functioning properly and that their claims are being paid as accurately as possible.”

Our unique audit process will help you return the maximum dollars to your bottom line. If your budget is already set for next year, an audit is still important because it will give you a strong comparison of your healthcare expenses so that you can strategically plan going forward. It really is never too late to take charge of your company’s healthcare expenses.

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.
looking at green dollar sign with magnifying glass

Healthcare Claims Audits: Are you auditing?

Your company needs to be conducting annual healthcare claims audits. YES, you are entitled to claims audits! Healthcare claims are one of the biggest expenses for companies that self-fund their employee healthcare plans. How do you ensure you are not overspending on claims?

Employer Healthcare Costs are Rising

Healthcare costs, to no one’s surprise, have continued to rise. This includes costs for services, costs to employers, and costs to individuals. While companies are picking up a large percent of the bill each year through premiums, the employees are seeing higher out-of-pocket costs, both in payroll deductions and overall deductibles.

Healthcare Claims Audits can help save employees money and keep deductibles from rising.
Average Annual Deductible for Employer-Sponsored Health Insurance Plans
Source: Statista.com

Healthcare claims audits help keep spending under control by finding overpayments and recovering funds. Then, that money can be used to retain the current benefit level or be invested in other company initiatives.

Employers cover about 70% of health-insured workers in the United States.

Employees still cite health insurance as the most desired benefit in the workplace. This benefit is usually the biggest cost outside of salary for employers.

Key Fact:

Health insurance expenditures totaled $3.6 TRILLION in 2018. If you’re one of the 99% of large firms that provide employee health insurance, you’re paying a big part of this tab!

A few more quick stats:

  • In 2020, the total direct written premiums totaled almost $825 billion. This was an 11% increase over 2019.
  • The average single-employee coverage cost to an employee was more than $7,000.
  • Employers cover the largest share of worker health insurance premiums, averaging about 30% of family premiums and 18% for single coverage. (Source: balancingeverything.com)

Don’t you want to know that your contribution is being managed properly? Healthcare claims audits are the way you can help control the financial integrity of your investment.

Why Healthcare Claims Audits?

Each year, 232 MILLION healthcare claims are filed in the United States.

Even if only 1% of the claims are incorrectly filed, that is more than 2 million mistakes. In fact, the industry average is almost 3% in errors. Unbelievably, this is considered acceptable. The truth is that mistakes are going to happen, but you CAN control the impact on your company with consistent healthcare claims audits. Two outcomes are likely. Both results protect your investment and return dollars to your budget for other uses.

  1. The audit finds overpayments & recoveries are returned to the company.
  2. If the audit is more than a random sample audit and instead analyzes every claim, the audit also finds systemic errors in the claims process. These findings allow solutions to be implemented so the same errors do not continue to cost your company money in the future.

What Do Healthcare Claims Audits Find?

Your healthcare claims are data sets. Trends are discovered based on a complete analysis of data. Once these trends are identified, policies can be reviewed and revamped as needed. This is not unique to healthcare claims audits. But, what is unique is that self-funding companies often do not know that they are in control of this data, not a third-party administrator (TPA).

You own this data. We can’t emphasize this enough. While TPAs often include basic audits in their service agreements, they are not financially motivated to ensure complete accuracy. Yet, not performing an audit can cost a company hundreds of thousands of dollars in overpaid claims. We are seeing more and more service agreements with language that is limiting a company’s right to audit all their paid claims and even discouraging outside audits. Do not sign agreements with this clause in place! TPAs are not our adversary. Rather, we work with them to save you – the main stakeholder – the most money. We do the work – so you don’t have to!

Key Fact:

Healthcare fraud costs the United States nearly $6 BILLION a year. Thankfully, most mistakes aren’t fraud. But when fraud does occur, it can mean substantial losses. Audits find the legitimate mistakes and the fraudulent claims.

Best ROI for Hours of Your Time

HR managers, benefits managers, and insurance brokers are already stretched thin. We get it! Our audit process lets you choose how involved you want to be in the process. If you only have a few hours to dedicate to exploring your audit options, that’s all we need. Once you’ve identified any specific issues and provided plan documents, we do the rest.

So, now that you know healthcare claims audits are an option, don’t wait. Start saving your company and employees money today! For more information on how our “every claim” audit is different, please read our blog “We do the work, you save the money.” Contact us directly at 800-646-9987 or online.

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.
don't shortchange employees circle image

How to Maximize Healthcare Cost Containment

*This article has been updated to include new information.*

Helping Human Resource Leaders become Healthcare Heroes!

At the upcoming Society of Human Resource Management (SHRM) conference, Healthcare Horizons will meet with hundreds of individuals tasked with ensuring that a company’s health insurance benefit is a viable option for their employees, without sacrificing coverage to reduce cost. The #SHRM21 theme was “Now More than Ever… It’s time for HR to step up and deliver.” The #SHRM22 theme “Cause the Effect” continues this idea that what HR does impacts every single aspect of a company and its bottom line. Healthcare Horizons helps human resource leaders maximize the cost containment of healthcare claims, allowing funds that would normally be spent on overpayments to be used for other worthy company initiatives.

Benefits are the #1 employee perk
According to GlassDoor, 57% of new hires cited benefits, and specifically health insurance, as a leading factor in their final decision to accept a job.

What does this mean for healthcare administration?

Human Resource departments play a part in many initiatives for a company, all designed to improve employee welfare and support company goals. One goal of the HR benefits manager is to provide healthcare benefits at the best possible cost, for both the employer and the employee.

Since healthcare is one of a company’s largest expenses, cost-containment is critical. Unfortunately, medical claims errors happen routinely in healthcare. Audits are vital to uncovering these errors and recovering funds. This process protects both the company and the employees.

Self-insured employers can lose millions of dollars each year in incorrectly paid medical claims. These errors drive the cost of insurance programs up, costing the employer and, consequently, the employee more.

Every time a claim is overpaid, an employee’s coverage is impacted. This may show up immediately through paying more out-of-pocket dollars toward a deductible. Or the impact may not be noticed until the next year when they see an increase in co-pays, deductibles, or premiums. From an HR perspective, this leads to unhappy employees.

charts showing rising cost of healthcare due to claim errors
Systemic errors in healthcare claim processing cost employers & employees money. Audits catch the mistakes!

How can we help with cost containment?

Performing regular healthcare audits benefits both the employer and the employee. “Every claims data set contains errors.  People aren’t perfect, mistakes happen,” says Beverly Healey, Operations Manager for Healthcare Horizons, and SHRM21 attendee. “Healthcare Horizons audit processes work with your third-party administrator to not only uncover incorrect billing but also to identify systemic issues that may be costing the employers thousands, even millions, over time.”

To learn more about how HR leaders can improve a company’s healthcare bottom line, stop by SHRM Booth #2870 or contact us directly.

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The Difference is in Knowing.
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.

Every Claims Data Set Has Errors – Part 2

Last month, we examined a few of the top categories of claims payment errors. Because every healthcare claims data set has errors — people make mistakes — it is important for self-insured employers to perform an independent, fully comprehensive audit annually to identify errors, correct  systemic issues for future savings and recover claims that were paid erroneously. 

Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly. It is an important fiduciary responsibility of the self-insured employer. 

In this blog, we take a closer look at three more common data set errors.

Top categories of claims payment errors

  • Duplicate payments
  • Eligibility
  • Coordination of benefits
  • Medical edits
  • Inpatient readmissions
  • Multiple procedure reductions 
  • Out of network reimbursement
  • Benefit maximums
  • Benefit exclusions 

Assistant Surgeon

Healthcare Horizons tests two common areas of overpayments for assistant surgeons: pricing and coding. Assistant surgeons usually receive a percentage of the normal fee schedule rate for the codes used with assistant modifiers, and we identify any claims paid that are greater than this rate. Additionally, we identify claims as possible overpayments for procedure codes that Medicare does not allow payment for an assistant surgeon. 

Hospital Mistakes

Many payers across the country have adopted policies to investigate and subsequently deny payment for hospital mistakes and avoidable conditions, such as objects left in a patient during surgery, fractures incurred in the hospital, blood incompatibility and certain types of infections. We put expert eyes on claims data for these types of hospital errors and expect recovery opportunities as more administrators adopt such policies.

Medical Edits

We apply medical edits to the claims data to identify mutually exclusive procedures and cases of procedure unbundling. Mutually exclusive edits identify procedure combinations that cannot be reasonably performed on the same patient on the same day. Unbundling occurs when a provider bills multiple component codes versus a single comprehensive code, often resulting in higher reimbursement. Payers have discretion over which medical edits to apply as there is not a commonly accepted group of these throughout the industry, so we are generally looking for a reasonable application of a set of edits and questions selected claims that seem to be clear errors.

While many self-insured employers will say “Our TPA has us covered,” and most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. Our expertise and ability to dig deeper into claims data sets allows us to deliver a better return on investment for our clients. 

The Difference is in Knowing.

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.

Every Healthcare Claims Data Set Has Errors

In this two-part series, we will examine a few of the top categories of claims payment errors. Missing these common errors means that self-insured employers are leaving possibly hundreds of thousands of dollars on the table every year.Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly.

It’s our job at Healthcare Horizons to take a closer look and return those dollars to the bottom line.

Top categories of claims payment errors

  • Duplicate payments
  • Eligibility
  • Coordination of benefits
  • Medical edits
  • Inpatient readmissions
  • Multiple procedure reductions
  • Out of network reimbursement
  • Benefit maximums
  • Benefit exclusions

Duplicate Payments

While most clients would expect duplicate claims to be rare, they are actually quite common in healthcare claims payments and usually result in recoveries on every project conducted by Healthcare Horizons. A recent audit turned up nearly $50,000 paid in error in just 10 duplicate paid claims.

Eligibility

It is important to validate coverage on the service date.  Employer groups often submit retroactive terminations to the administrator, resulting in an opportunity for overpayments unless the administrator has a process in place to identify and recover these claims. In addition to claims paid after the termination date, Healthcare Horizons identifies claims paid during a gap in coverage and claims paid without an eligibility record on file.

Multiple Procedure Reductions

When multiple services are performed in the same session, secondary procedures are priced at a reduced percentage (usually 50 percent) of the normal contract rate. This automatic reduction accounts for savings gained by only having to prepare a patient once for multiple procedures. We flag claims that may have missed this standard discount by reviewing the secondary procedure allowance.

We often hear the words, “Our TPA has us covered,” and while most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. People make mistakes. Healthcare Horizons is committed to finding every claim and every possible dollar for our clients.

The Difference is in Knowing.

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.