Podcast

new year goal through a magnifying glass

New Year Goal: Fiscally Sound Self-Funded Health Plan

Is a key company New Year goal to have more fiscal control of your self-funded insurance plan? If so, there is one important message you need to hear and one important step to take to help protect your plan.

Not Everyone is Looking Out for You

If you take away nothing else from this information, heed this message: the only person concerned with maximizing your investment is you.

When companies self-funds their medical plan, they are responsible for every aspect of the plan – from full payment to legal requirements. Other plans have varying levels of partnership between a fully-funded plan and investment by the company. As corporations grow it often makes more sense to eliminate the go-between in funding and payment, not only to save on costs but also for more flexibility on the plan offerings.

While third-party administrators (TPA) can and do help manage self-funded plans, the TPA has no financial incentive to control costs. Their money is not on the line. When your financial balance sheet is the one directly impacted, you are much more likely to review payments and processes more carefully.

Audits are Insurance for Your Plan

So, what one step best ensures that you aren’t overpaying medical claims? Annual comprehensive claims audits.

Let’s be honest, human resource executives and benefits managers are busy. Few have the time to review the vast volume of medical claims submitted through employer-funded insurance policies. Even if they did, they may not have the specialized knowledge to properly identify the many types of possible errors. The good news is that they don’t have to!

A true comprehensive audit process is not a software solution. If it were, the same logic would be built into claims systems to stop overpayments from happening in the first place. We audit all aspects of the adjudication process from receipt to payment of the claim. Our comprehensive approach has offered our audit team a reference point for every kind of error possible. This has allowed us to recover millions of dollars in overpayments for our clients.

When our team is on site (physically or virtually), we work individually through each claim selected to resolve the specific questions that arose in the data-mining phase of the project. When the site visit is complete, we look back at the entire dataset to find all additional occurrences of systemic or repeatable errors. Healthcare Horizons customizes the most comprehensive audit process possible for every one of our clients to ensure positive outcomes. Once our audits are complete, we will make plan benefit recommendations for improvement and root cause correction.

The audit is designed to be a positive process between Healthcare Horizons, the client, and their administrator. We take pride in the excellent working relationships we have developed with third-party administrators and our clients. Healthcare Horizons may occasionally request assistance from the client when a clear definition of plan intent is required. Additionally, we can provide guidance to help our clients negotiate direct credits and monitor the recovery of claims payments until the client is satisfied. Whatever you choose, the goal is to return the most money to your bottom line. After all, it’s your company’s money and it should be available to use to provide more benefits to your employees.

Achieve Your New Year Goal with a Sound Plan

Fortunately, while the idea of a comprehensive audit may sound daunting, Healthcare Horizons is committed to identifying errors that will provide a positive return on investment for our clients, while comprehensively assessing the performance of claims payers.

So, this year, keep your resolution to make your self-funded employee health benefits plan as financially sound as possible. Schedule your free assessment to get started returning overpaid claims dollars back to your company’s bottom line, where they belong!

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.

Unwrap the Gift that Keeps on Giving

Tis the Season for Savings

open gift that keeps on giving with red ribbon

It’s the time of year when we look forward to festively wrapped gifts. We eagerly anticipate tearing open the paper to see what’s inside. But what if we told you there’s a gift that keeps on giving all year round?

A Year-Round Gift that Keeps on Giving

Comprehensive medical claim audits are the ultimate gift for your business. By examining every medical claim, we uncover hidden costs and ensure accuracy, ultimately boosting your bottom line.

How Does this Magic Work?

Our team of elves is dedicated to helping you maximize your healthcare dollars year-round. We’ll work to:

  • Identify Potential Overpayments: Our advanced auditing techniques can uncover hidden charges, duplicate payments, and other billing errors.
  • Recover Lost Funds: We’ll work diligently so you can recover any overpayments, ensuring that you receive the maximum reimbursement.
  • Optimize Your Plan: We can provide valuable insights to help you prevent future errors and understand best practices in healthcare claims management.

Is the Grinch Lurking?

Unfortunately, medical billing errors are a common occurrence. These errors can result in significant financial losses for your business. Don’t let the Grinch of medical billing steal your self-funded dollars. By choosing comprehensive medical claim audits, you’re taking charge of your business’s financial health.

Ready to Unwrap Your Gift that Keeps on Giving?

Don’t wait for a holiday surprise! By proactively auditing your claims, you can reclaim overpaid funds and put them back where they belong: in your business. We are a leading medical claims audit company for a reason. Healthcare Horizons provides:

  • Expertise: Our team of experts has years of experience in auditing medical claims payments. We likely have seen every scenario that impacts your self-funded health care plan. That experience means our team knows what red flags to look for to identify errors.
  • Proven Results: We have a proven track record of helping businesses recover significant funds. Whether we find a systemic error that could add up to millions of dollars of overpaid funds or a one-off claim that was wrongly charged to your plan involving thousands of dollars, it is your money and we will work to help you get it back.
  • Client-Focused Approach: We work closely with our clients to understand their specific needs and goals. You choose how much or little you want to be involved in the process.

During this holiday season, don’t get caught up in the frenzy of shopping, cooking, planning, and celebrating and then forget about one of your biggest business expenses. Contact us today to schedule a consultation and learn how our medical claim audit services can ensure you receive the gift of savings all year round.

happy holidays! in script with red background promoting gift that keeps on giving

Recovering Humanity

At Healthcare Horizons, a significant part of our workday is spent finding and recovering unexpected overpayments in our clients’ self-funded insurance plans. However, this month, rather than focusing on identifying mistakes in healthcare claims, we would like to turn our attention to recent events and the importance of those dear to us.

Unexpected natural disasters hit many people close to us this past month. Hurricane Helene devastated vast areas, including those close to our home in Knoxville, TN. Many of our team members have friends and loved ones who live in the Appalachia region that were severely impacted. One of our clients and most of its employees are located in the state of North Carolina. Watching as their lives were completely disrupted by these events is a humble reminder of the power of nature.

But, as we see so often, the positive shines through. The number of people from around the country who reached out to our office to ask if we were okay was heartwarming. Most moving, though, was watching communities and strangers rally together to provide help during these challenging times.

We learned of families without power opening their doors to neighbors to provide temporary homes. We heard stories of teachers doing wellness checks for several days after the storm until all students were accounted for. We saw truckloads of equipment and supplies brought by good Samaritans from many states to fill immediate needs of food and water.

The examples of fellow humans simply caring for others are innumerable. We so often hear about our differences and disagreements. Yet, in times that are the most challenging, it doesn’t matter what you look like, who you vote for or what beliefs you hold. What matters is that an actual person needs help – and someone is ready to step up.

A Most Thankful Thanksgiving

This Thanksgiving, we are filled with gratitude for the countless individuals who stepped up to help. We are thankful for the love, support and generosity shown to those affected by this disaster.

We wish for everyone to find comfort in the company of loved ones this Thanksgiving. May the spirit of goodwill continue to inspire us all, long after the crisis has passed, and a sense of normalcy returns.

If you would like to help with the ongoing recovery efforts in North Carolina and Tennessee, remember the small businesses during this holiday season. Tourism is reopening in many places. Other businesses are ramping up their online efforts. Below are two links, one with updated information on tourism and the other to provide financial support.

 https://always.exploreasheville.com/

https://pay.payitgov.com/ncdonations

scary zombies in window trying to get inside

The Scary Alternative to Medical Claims Audits

Medical claims audits aren’t scary, but the results of not performing them can be frightening! Audits are best practices in the healthcare industry, especially for self-funded health plans. Comprehensive audits involve a thorough review of claims to ensure they are accurately paid on behalf of the self-insured client.

Still hesitant about conducting medical claims audits…

What’s the Worst That Could Happen?

  • The Alien Abduction Claim: An employee submits a claim for medical expenses incurred during an alien abduction. The auditor, being a rational person, dismisses the claim as a prank. However, the employee insists that the aliens had performed a complex procedure and provides evidence in the form of a shiny metal implant.
  • Time Traveling Employee: Imagine your employees submitting claims for tickets to the future or the past, citing “historical research” as the reason.
  • The Ghostly Illness: An employee submits a claim for treatment of a mysterious illness that only manifests when the employee is alone at night. The auditor, unable to verify the claim, recommends a consultation with a paranormal investigator.
  • Furry Family Members Submit Claims. Picture your employees submitting claims for their cat’s laser eye surgery or their dog’s dental cleanings.

Okay, so these scary scenarios are a bit far-fetched.

But the point is, finding errors in your medical claims ISN’T the worst thing that can happen. The WORST thing that can happen is that you DON’T find the errors – costing your company thousands, if not millions, of dollars. Addressing issues now can save money when the same error repeats year after year after year.

Why Audits Are Healthy  – not Scary – for Self-Funded Plans

  1. Identifying Errors and Inefficiencies: Audits can help uncover errors or inefficiencies in your claims processing that may be costing your plan money. Healthcare Horizons’ comprehensive audits review every healthcare claim and specifically target claims to review onsite with the carrier, 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. By identifying these issues, you can take steps to correct them and prevent future losses.
  2. Ensuring Fiduciary Responsibility: Legal experts are sounding the alarm about growing compliance risks as more healthcare costs are funded by employee contributions. This raises the importance of protecting the fiduciary responsibilities of employers. We believe one of the most fundamental elements in corporate oversight is sadly lacking in healthcare benefits administration at many companies – effective audit policies and practices. Many self-insured companies fail to have an annual audit of paid medical claims. Our comprehensive audit provides assurance that companies and employees’ healthcare costs are not being inflated by payment errors and abusive claims.
  3. Improving Plan Performance: Following best practices in healthcare claims management ensures the plan matches client intent, provides oversight of the administrator to ensure accuracy, implements cost-containment measures achieved by correct payment processing and identifies areas to eliminate fraud, waste and abuse.

Healthcare Horizons can help you avoid common and hidden nightmares by providing a streamlined and efficient audit process. We also return overpaid dollars to your company bottom line. Don’t let fear or uncertainty hold you back. Contact us today to learn more about how we can help your self-funded health plan.

Curious about the types of discoveries we make in our audits? Check out our Lost Benjamins chronicles if you want to read something really scary!

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.

How to Grow Your 2025 Healthcare Budget

In today’s competitive healthcare landscape, managing costs effectively is crucial for the sustainability of healthcare benefits for an organization and its employees. The budget process, encompassing everything from forecasting to allocation, is a cornerstone of financial health. For companies self-funding their health insurance plan, this process is even more important. While the budget process might seem straightforward on the surface, it’s often fraught with complexities that can impact both the financial health of the organization and the quality of benefits offered to employees. It’s time to grow your budget!

The Challenges of Self-Funded Healthcare Budgets

As you crunch numbers and prepare your 2025 budget, healthcare spending can be one of the more difficult line items to predict for numerous reasons:

  • Rapidly Evolving Healthcare Costs: Healthcare costs continue to rise at a significant rate, making it difficult to accurately predict future expenses.
  • Unpredictability of Needs: While past data is helpful, illness and injury cannot always be planned for and may be more serious than expected.
  • Regulatory Changes: The healthcare industry is subject to frequent regulatory changes, which can impact both costs and compliance requirements.
  • Emerging Healthcare Trends: New technologies, treatments, and care delivery models can introduce both opportunities and risks to the budget.
  • Data Complexity: Analyzing and interpreting complex healthcare data can be time-consuming and challenging for organizations without specialized expertise.

Enlist Help to Find Lost Dollars and Grow Your Budget

While benefits managers may have a strong understanding of their organization’s needs and the history of their plan, they may lack the specialized knowledge and tools required to navigate the complexities of self-funded healthcare budgets for the reasons mentioned. Partnering with a professional benefits consultant can provide the expertise and support needed to ensure the sustainability of healthcare benefits and protect – or even grow – the healthcare plan budget. One tool to achieve this goal is a healthcare claims audit.

Healthcare claims audits ensure accuracy, identify potential fraud or abuse and recover overpayments tied to employer healthcare plans. At Healthcare Horizons, we use a comprehensive audit method to track every claim and recover the most dollars possible. Our experienced auditors are adept at recognizing the red flags in a healthcare data set that may indicate an overcharge, systemic error (one that keeps repeating and snowballs into huge losses) or fraud. Once a claim is flagged as suspicious, we begin the process of working with the third-party administrator to correct the mistake. Once all parties agree the issue has been properly identified, the overpaid dollars are returned to the plan’s bottom line.

Healthcare claims errors typically range from 1 to 3 percent of total claims and can cost employers hundreds of thousands of dollars annually. That is a substantial piece of a budget.

Don’t Miss Out on Funds in Your Next Budget

Healthcare claims audits are an excellent tool to protect your self-funded healthcare plan. However, this strategy is most effective when combined with a solid service agreement with your third-party administrator. We will also review your current service agreement to ensure that it includes full audit rights. Limited (such as random sample audits) audit rights mean you can’t control what is analyzed – or how much money you may be entitled to have returned.

By leveraging the insights and tools offered by professionals, organizations can make informed decisions, optimize their budgets and protect their financial health in the face of an ever-changing healthcare landscape.

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.

Negotiating Now Means 2025 Healthcare Savings!

Don’t Miss Your Negotiating Window!

Attention businesses with self-funded healthcare plans! While your team may be enjoying some well-deserved vacation time, third-party administrators (TPAs) and benefits managers are negotiating Administrative Services Only (ASO) agreements for 2025. This is a critical time to ensure your company gets the best possible deal, especially when it comes to audit rights.

Audit Rights are for Your Protection.

Self-funding healthcare plans offer cost-saving benefits, but they also come with fiscal responsibility. You’re on the hook for claims paid by the administrator to providers. Strong audit rights allow your company to verify the accuracy of those claims, potentially uncovering errors or extra fees and saving you significant money. But if you don’t have the appropriate audit rights, you could get burned and your savings washed away.

Don’t Bury Your Head in the Sand!

Many companies have no idea they should be auditing their claims data. HR executives and benefits administrators might think their broker or benefits consultant manages everything – but that’s a dangerous assumption. The responsibility for identifying and correcting errors falls on you.

During negotiations, ensure that your ASO agreement does not restrict your ability to audit the payer’s work. Here’s what you need to do:

  • Review your current ASO agreement: Understand your existing audit rights and identify any limitations.
  • Research industry standards: Benchmark your current agreement against what other companies are negotiating.
  • Negotiate for comprehensive audit rights: Push for the ability to analyze all claims data, select targeted claims for review versus random sample selection, and review provider contracts.

Get Help Protecting Your Bottom Line!

Healthcare Horizons is here to empower businesses like yours in your audit agreement negotiations, as well as with your comprehensive healthcare plan audits. We offer a complimentary ASO audit language review and provide recommendations to help you negotiate the best audit rights. This can be a valuable starting point for ensuring that your plan isn’t overpaying for healthcare benefits!

By acting now, you can ensure your ASO agreement delivers on its cost-saving promise for 2025. Don’t miss out – negotiate for robust audit rights, protect your company’s bottom line, and take advantage of Healthcare Horizon’s free audit language review. Contact us today at www.healthcarehorizons.com or 800-646-9987.

 

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.
hand wearing white glove holding money from healthcare savings

White Glove Service Maximizes Your Healthcare Savings

There’s a hallmark of excellence that signifies the ultimate in care and attention: white-glove service. It is more than getting the job done. It’s about exceeding expectations and creating a truly personalized experience.

At Healthcare Horizons, we embody the spirit of white-glove service. We go beyond simply meeting your needs. We actively exceed expectations at every turn. But what does that mean in practice?

Translating White Glove Service into Action

Anticipating Your Needs: We understand that time is money. That’s why we go beyond simply identifying problems in your medical billing. We take a proactive approach, constantly looking for systemic issues and implementing solutions to prevent them from recurring. This ensures you don’t face the same headache twice.

Your Success is Our Priority: We genuinely care about your bottom line. We work tirelessly to help you save money on your medical payments by identifying errors and discrepancies in your payments. Every dollar we recover for you is a dollar that goes back into your pocket. Think of it as reinvesting in your business.

A Customized Approach: A one-size-fits-all approach doesn’t cut it. We understand that every client has unique needs. That’s why we customize our audits to fit your specific situation. We take the time to understand your business and tailor our services accordingly. This ensures you get the most out of our expertise, addressing your specific challenges and maximizing your savings.

Transparent Communication: Audits can be stressful. Our white-glove service insists on clear and consistent communication throughout the process. We keep you informed of the progress, explain findings in an easy-to-understand manner, and are available to answer any questions you may have. This transparency fosters trust and empowers you to make informed decisions about your reimbursement options.

Following Through with Excellence: Our job doesn’t end with the audit. We believe in white-glove service that extends beyond the initial process. We are here to support you every step of the way. After your audit is complete, we will follow up to monitor your recovery activity, answer any questions you may have, make recommendations, and ensure you have the resources you need to move forward.

A Committed Partner to Your Success

We strive to create an exceptional client experience that builds lasting relationships. At Healthcare Horizons, your needs are our top priority. We understand that navigating the world of healthcare claims audits can be complex and overwhelming. That’s why we become your hands-on team, guiding you through every step. We collaborate with other parties involved in your plan, but our ultimate responsibility lies with you. Your success is our focus – that’s the white-glove difference we offer.

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.

Audits are an Insurance Policy for Self-Funded Healthcare Plans

Your home is the result of hard work, and a sizable investment. You do everything you can to protect your haven. That includes homeowner’s insurance – a shield against unexpected storms, both literal and financial.

But what about your healthcare plan? Self-funded medical plans offer a compelling alternative to traditional fully insuranced plans, empowering you to control costs and potentially save money. However, self-funded plans are vulnerable to hidden dangers. Without proactive solutions, uncovered errors and overpayments can lead to significant financial losses on medical claims – a storm best avoided.

Your self-funded healthcare plan needs a strong defense system. That’s where comprehensive audits come in. Think of comprehensive audits as your proactive insurance policy for self-funded healthcare. They function similarly to a homeowner’s insurance policy in several ways:

  • Risk Mitigation: Homeowner’s insurance protects against potential disasters, like fires or floods. Audits act preemptively, identifying and addressing errors before they lead to significant financial losses.
  • Financial Protection: Both homeowner’s insurance and audits provide financial protection. Homeowner’s insurance reimburses you for covered damages, while audits recover overpayments on medical claims, protecting your healthcare budget and company bottom line.
  • Peace of Mind: Knowing your home is insured offers peace of mind. Similarly, comprehensive audits provide peace of mind by ensuring the accuracy and efficiency of your healthcare spending.

Our team of experts reviews your medical claim data sets, looking for red flags in submitted claims. We protect against:

  • Coding Errors: A simple typo or incorrect code can lead to significant overpayments. Audits catch these errors, ensuring employers are billed appropriately for services rendered.
  • Duplicate Charges: Audits uncover these hidden costs, making sure you’re not paying twice for the same service.
  • Inflated Prices: Medical bills can be complex, with hidden markups and unnecessary charges. We have reviewed hundreds of service agreements and are very familiar with reimbursement rates, fees and other valid charges. So, when we see one that is suspicious, we recognize it as a potential area for reimbursement.

Beyond Financial Protection

Self-funding offers significant flexibility and cost savings compared to fully insured plans.  However, like any valuable asset, it requires protection. As an HR director or benefits manager, you are tasked with providing positive programs for your company’s employees. One of the most requested is a robust healthcare plan. Be sure you are protecting your company’s sizeable investment with annual comprehensive audits. Audits offer more than just financial protection. They provide valuable insights into potential plan design improvements. By identifying trends in overpayments, you can refine your plan to minimize future errors and maximize cost savings. We partner with you to ensure your self-funded plan remains a financial benefit, not a hidden liability. 

Learn More Here

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Contact us today for a free consultation and learn how our comprehensive audits can serve as the insurance policy against overpaying on medical claims. Heading to Chicago for SHRM 24? We would love to meet you and talk with you about your challenges. Visit us at booth #1557 to have your questions answered and to enter our raffle!

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.
word joke in circle with line through it

There’s Nothing Funny about Skipping Claims Audits

Skipping Audits is No Joke

Chicago is known for a lot of things – hotdogs, deep-dish pizza, frustrated baseball fans and even wind. However, another aspect it’s known for is its history of comedy. With The Second City and a multitude of improv halls, it only makes sense that this year’s SHRM conference in Chi-town is featuring many well-known comedians as star-studded bonuses to the networking conference.

After you see Jay Leno or Sherri Shepherd, we invite you to stop by and see us to learn more about why skipping healthcare claims audits of your paid medical claims is no laughing matter.

Past attendees indicate that one of the reasons they attend the SHRM conference is to discover cost-saving initiatives that are important to their companies. Human resource executives are continually looking for ways to improve benefits without increasing expenses to the employer or employees. Since health insurance is consistently the most important benefit desired by employees, it’s important for HR directors and benefits consultants to find innovative and sustainable ways to keep costs manageable. A comprehensive claims audit is one tool to accomplish that goal.

Top 4 Benefits of a Comprehensive Claims Audit

Reviewing medical claims data is the only way to know for sure if your plan is administered correctly. Comprehensive audits include a review of the entire data set so that egregious errors aren’t missed (image if a random sample audit missed a 100-thousand-dollar mistake). By having annual audits, you ensure that your company is:

  • Not overpaying claims or paying claims in error
  • Identifying and eliminating systemic errors
  • Ensuring recovery of overpayments within the TPA’s timing limitations
  • Fulfilling the fiduciary responsibilities as a self-insured employer

Comprehensive claims audits have one overarching goal: to return dollars to your bottom line. You would not accept overpaying your credit card bill or allowing bank errors to go unresolved. And you would most assuredly hold someone accountable if processes were systemically in place that caused mistakes. The same is true for your self-funded medical plan. Every time you overpay for medical expenses, your plan loses money, and your employees are negatively impacted – both through the types of benefits you can continue to offer and through paying more in premiums or co-pays.

Read more: Top 10 Audit Questions

Stop the cycle! Let’s talk about your company’s needs. Call us at 800-646-9987 to schedule a meeting at the SHRM conference or visit us at booth 1557 to ask your audit questions and enter to win a unique prize!

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.

Top 10 Medical Claims Audit Questions

We know comprehensive medical claims audits are the best way to protect your company’s self-funded health insurance investment. We also know that the claims audit process can seem intimidating. But it doesn’t have to be! Here are some of the most common questions we are asked. We would love to talk with you about claims audits and how we can help you return overpaid dollars to your bottom line.

1.     What type of medical claims audit should we choose?

You have two options for audits: random sample and comprehensive (also called Targeted or Focused). We perform comprehensive audits, where 100% of your claims data is analyzed, because we know that random sample audit findings are the luck of the draw. Unfortunately, your administrative services only agreement (ASO) may limit you to random sample audits. Random-sample audits are better than not performing an audit at all; however, random-sample audits can leave thousands of dollars behind. We can help you evaluate your audit rights at no charge to make sure you have access to the most effective audit available.

2.     How much does a comprehensive audit cost?

Our customized, flexible pricing options are designed to meet your needs and accommodate your TPA requirements. Our fixed-fee pricing ensures you know exactly what your out-the-door audit cost will be and is most often covered by the recovered dollars. We also offer a risk-free, contingency pricing structure that is based on what we collect, not on the errors we identify.

3.     How much money can I expect to have returned from each audit?

It is difficult to estimate a rate of recovery, but on average .5%-1% of the total annual medical spend is returned. Recovery amounts depend on several factors including:

  • The amount of the overall claim
  • The number of claims an ASO allows to be analyzed
  • The age of the claim (most ASOs won’t allow recoveries of claims older than 12-18 months, which means annual audits are a must!)

4.     How much time do I need to set aside for the audit?

While we welcome any involvement in the audit process from our clients, the time commitment of the client is minimal. The client must review and sign the contract and Business Associate Agreement, provide plan documents and once the audit is complete – review the audit report. Below is helpful information a client can provide to enable us to ensure the best pricing.

  • Client Name
  • The Third-party administrator (TPA) processing claims
  • Total annual medical spend
  • How many subscribers/members on the plan
  • Number of plan designs offered (HDHP, PPO, etc)
  • Audit rights (Comprehensive 100% audits rights versus random sample selection; fixed fee pricing versus contingency pricing)

5.     What communication can I expect during the audit process?

We will send updates to your company’s point of contact throughout the audit process. These check-ins include:

  • Proposal that outlines our audit process, categories of testing, and projected cost
  • Preliminary findings of the initial review
  • Final audit report that includes dollars associated with recoveries, our final audit comments in response to the TPA, and recommendations on best practices
  • Any post-audit communications we receive from the TPA on the recovery process

There is no time limit on our availability post-audit. We are happy to answer any questions.

6.     How long does an audit take?

Audits typically take 4-6 months to complete. The length of an audit is largely dependent upon receipt of viable data, the TPA timeline for preparation of the audit and scheduling the virtual site visit. (POTENTIALLY INSERT TIMELINE GRAPHIC – YES that would be good here)

7.     Are there any performance guarantees?

We do not offer performance guarantees, which often do not represent true success. Our commitment to our clients is to continually look for ways to do what we do better. Accuracy is important in our business. We are constantly refining our data mining process to find every error possible to yield higher recuperations for our clients. We believe that our long-standing relationship with numerous clients is a testament to our performance and accountability.

8.     What experience does Healthcare Horizons have in our industry?

Healthcare Horizons has been exclusively performing healthcare claims audits for self-insured employers for the past 24 years. We perform audits for companies in a multitude of industries, but our process remains the same no matter the industry of our clients. This breadth of experience across many different employers, industries, and claims administrators allows us to bring industry best practices to each project. It also provides us with the benefit of having seen almost every benefit setup, provider contract method, and claims administration policy that one would expect on a claims audit.

9.     How do you work with our TPA? Will performing an audit negatively impact our TPA relationship?

Third-party administrators are partners in helping recover as many overpaid dollars as possible. The TPA works with Healthcare Horizons to provide the medical claims data set, provide necessary reports surrounding the targeted sample selection and engages in dialogue concerning findings. Since audits should be an included provision in an ASO, the TPA expects that you will uphold your fiduciary responsibility to ensure the best management of your health insurance plan investment.

10. How do you ensure privacy and compliance mandates are met?

While sponsors of non-Federal government health plans may elect to exclude certain categories or plans for privacy reasons, doing so can impact findings and monetary returns. We understand that data integrity and security are top priorities and so we maintain exceptional administrative, technical, and physical safeguards to protect the confidentiality, integrity, and accessibility of protected health information consistent with the requirements of HIPAA policies.

Don’t let unanswered questions halt your medical claims audit.

Medical claims audits are valuable resources to protect one of the biggest expenses in your business. We are happy to review the audit rights language in your administrative services agreement at no charge to help determine the correct audit approach for your company, as well as make suggestions for future negotiations with your TPA. Don’t pay more in claims than you are required to pay! Get your questions answered and start the audit process today!

Are you going to be at SHRM 2024? Call us at 800-646-9987 to schedule a meeting or visit us at booth 1557 to ask your audit questions and enter to win a unique prize!