Podcast

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!

 

three-way tie for winner

Your 2024 Lost Benjamin Award Winners

Lost Benjamin Awards highlights recovered dollars from comprehensive claims audits

It’s a Three-Way Tie

Our 2nd annual Lost Benjamin Award voting ended in a three-way tie! The most interesting thing about the winners is that they address each of the fundamental issues we commonly see in healthcare claim errors.

Systemic Errors Add Up

Benefit Errors Cost More Than 7 Million Dollars – Healthcare Horizons

Errors that aren’t caught can multiply and cost your business significant amounts of money in overpaid claims. When the error is a set-up or system issue in the processing of the claims, they are generally referred to as systemic errors. These errors can be small and often go unnoticed. One or two doesn’t seem to be a big deal. However, if the root of the problem isn’t addressed, that “no big deal” will quicky grow to a significant hit to your self-funded health care plan. That’s what happened in this case. Smaller errors went left unchecked for years and added up to a $7 million problem!

Persistent Review of Service Agreements

Seven is a Lucky Number! – Healthcare Horizons

You want to work with an audit company that won’t take no for an answer! With decades of serving clients and decades upon decades of employee experience, we recognize when something isn’t right and know how to fix it. Not only was a keen eye needed to spot this error, but once found, patience and persistence were required. The client’s TPA was convinced a fee included on multiple claims was appropriate as part of their agreement. Except, they couldn’t point out where the fee language originated. We recommend an annual review of your service agreements to make sure all the administrative fees are correctly explained.

Human Errors Can be Costly

Drowning in an Overpaid IV Claim – Healthcare Horizons

Safeguards should be in place to catch mistakes, especially the ones that defy logic. Unfortunately, not only do humans make mistakes, but they also don’t like to admit it when they do! While we aren’t playing the game of gotcha, we are good at finding those errors that make you scratch your head. And when we do, we believe correcting the error as soon as possible is the right thing to do. This winner was a classic example of a mis-entered claim, and the subsequent pushback from the TPA before the overpayment was returned to the client and their bottom line. Thankfully, we were able to outline the mistake and get everyone on the same page.

Sadly, This Isn’t the End

Nominations have started for next year’s awards. We continue to find overpayments in healthcare claims that are costing companies and their employees. You can bookmark the link here so you don’t miss an entry. Do you have an egregious claim error to share? Send your story to hhadmin@healthcarehorizons.com. Even more importantly, be sure you are having your claims reviewed with a comprehensive audit so that you don’t see your error on our award list!

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.
stethoscope over lines showing rising healthcare costs

Control Rising Healthcare Costs by Reviewing Data

Rising Healthcare Costs Can be Tamed

 

In a recent blog we talked about the impact of inflation on businesses and how prudent executives are seeking ways to save money that will then help fund desired employee programs. Unfortunately, as reported in this SHRM article, rising healthcare costs are outpacing inflation.

doctor looking at tablet trying to reduce rising healthcare costs

The cost of medical care benefits in the U.S. is projected to increase about 8.9 percent in 2024, compared with 8.2 percent in 2023.

Medical costs for employer-sponsored plans, which includes improved technologies, overprescription of treatments or lack of preventative care, continue to outpace inflation, rising on average between 6.8 percent and 7.3 percent.

Some suggestions in the article to flatten the trajectory of the price increases include telehealth options, more well-being services and taking stock of existing benefits. Before any new policies or options are implemented, however, we recommend a comprehensive review of self-funded healthcare claims payments. Only with a professional review can you fully aggregate and analyze health data to identify waste, abuse, or just plain mistakes. Health analytics can then be used to drive process improvements and eliminate ineffective interventions that inflate costs more than necessary.

Find Multiplying Systemic Errors

There is no better time than now – the start of a new year amid soaring costs – to schedule a professional audit of last year’s healthcare claims data. Not only will a healthcare claims audit find instances of overpaid or misallocated claims, but a comprehensive audit will correct any systemic issues that could be carried into 2024. If imbedded problems are not addressed, not only will a self-funded company pay more in increased costs from providers, but the company will also pay more in erroneous claims. If left unchecked, those incorrect claims will keep occurring and the lost dollars will keep growing.

Systemic issues can include abusive and fraudulent practices or inadvertent errors. Fraudulent practices are those that involve intentionally billing at an incorrect rate.

  • Upcoding – This involves systematic billing for services at a higher rate than what was actually provided. For example, billing for a 30-minute physician office visit when the patient only received a 15-minute visit.
  • Unbundling – Breaking what should be one billing code for a group of procedures into multiple individual codes to maximize reimbursement. This leads to inflated charges.
  • Medical necessity errors – Billing for services that aren’t medically necessary for the patient’s condition or care plan. Services should meet insurance criteria for necessity.

Other systemic errors occur due to incorrect information being given to claims processors, leading to ongoing data entry mistakes.

  • Incorrect coding – Using the wrong billing code for a service rendered, resulting in incorrect payment rate. Coders may consistently enter certain services incorrectly.
  • Coordination of benefits errors – Failing to properly coordinate claims with secondary insurers results in overpayment from the primary insurer. Information systems may have incomplete secondary payer data.
  • Eligibility verification failures – Providing services without confirming active health plan enrollment and eligibility, risking denial of claims. Systematic verification checks may be inadequate.

The Cost of Waiting is High

Waiting to find the errors in your healthcare claims data is costing your company money. That money could be passed on to plan participants through reduced deductibles. Or the savings found in duplicate payouts, as an example, can be returned to your bottom line and help fund other initiatives. Costs may be rising, but that doesn’t mean you are without recourse. Contact Healthcare Horizons for an initial review of your administrative plan to determine your best next steps to minimize the impact of rising costs.

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.
inflation letters cutting through a hundred dollar bill

Fight Inflation in the New Year

Don’t Let Inflation Impact Your Healthcare Offering

Every year, saving money or better managing finances is in the top five on New Year’s resolutions lists. Businesses are no different. Your company may have just finished its budget review, or you may be planning during Q1, but the goal is the same: end 2024 with more profit than last year.

If the only things factored into your success were your income and expenses, it would be easy to ensure that your end-of-year number would be positive. But, just like our home finances, your business’ bottom line is impacted by external pressures, like unexpected maintenance expenses, personnel leaves of absence or even federal regulations. The biggest pressure facing families and corporations, however, is inflation.

Inflation Impacts All Aspects of Business

Some economists estimated an 8% inflation rate for 2022 and a 4.5% rate for 2023. While 2024 rates are expected to level off to around 3%, the impact of the significant rise in prices on goods over the past three years will be felt for years to come. Salaries will continue to be adjusted to allow employees to afford increased prices on groceries, utilities and rent. More dollars will need to be allocated to healthcare as well, by both individuals and companies. Fortunately, there are steps benefits administrators or human resources professionals can take to lessen the impact on a company’s bottom line.

Audits Drive All Solutions

To reduce expenditures from your self-funded health care plan, you must understand how your funds are administered. To do this, you need to audit your healthcare claims fully. Comprehensive audits that review 100% of your healthcare claims provide valuable insights, including patterns of inaccurately billed claims, and identify the best way to reclaim overpaid dollars. Transparency helps policymakers develop effective strategies to combat inflation in healthcare payments.

Once armed with the information garnered through your audit, you can use your findings to negotiate lower rates with providers, thereby reducing overall healthcare costs. As you find cost savings through better rates and reclaimed dollars, you can then advocate for policy change through implementation of targeted cost-containment measures, such as prior authorization programs or utilization management initiatives, which can further mitigate the impact of inflation.

It’s important to note that healthcare claims audits are not a one-size-fits-all solution to inflation. However, when implemented effectively, they can be a valuable tool for protecting against rising healthcare costs and ensuring that resources are used efficiently and effectively.

This new year, make your top business resolution to boost the fiscal health of your self-funded health care plan. Call today for a complimentary review of your current administrative plan and learn how our audit process can help your company’s bottom line.

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.
globe with world celebration lights in background

A World Full of Celebrations

Winter celebrations are as diverse as the world we live in. While some revel in festive gatherings, others cherish quiet moments with loved ones. No matter how you choose to celebrate, this time of year is a time to come together with loved ones, to make special memories and to cherish the bonds we share.

Whether you light candles to celebrate Hanukkah, exchange gifts under the Christmas tree, seek enlightenment during Bohdi Day, honor African heritage through Kwanzaa, embrace the ancient traditions of the Yule Festival, or any of the traditions that you hold dear, Healthcare Horizons wishes you a joyful season. As always, our mission throughout the year is to protect the privacy of our clients and their employees, recognize our staff and clients as our most important assets, and uphold the highest ethical standards.

In the world of healthcare auditing, where numbers reign supreme, we strive to never forget that there are real people behind the data. Every claim is an individual struggling with the complexities of healthcare or an employer wrestling with the rising costs of providing health insurance. These are the faces behind the numbers, the human stories that drive our commitment to excellence. No matter what the differences are in our society, at Healthcare Horizons we remain committed to providing our clients with the same unwavering level of service and acting in your best interest. We are grateful for the opportunity to serve you and to help you navigate the complexities of healthcare auditing.

Together, let us embrace the diversity that enriches our lives and celebrate the spirit of winter, a season that reminds us of the enduring beauty of the human spirit and the simple joys that bring us together.

All types of people…all types of celebrations…all types of claims…but one same wish: finding those moments that create lasting memories.

Happy Holidays from our house to yours!

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.
woman with eyes closed clasping hands and smiling

Thankful Thoughts from Our Clients

A twine circles the word thankful

For nearly thirty years we have had the opportunity to work with a wonderful group of clients in multiple industries across the country. We are thankful for their confidence in our services, and we are equally thankful and humbled by their words of appreciation. Read below for a sampling of the kind affirmation we have received.

Why Our Clients are Thankful for Us

Thoroughness

Our comprehensive claims review means that we find more errors than random sample audits do – returning more dollars to our clients. When we say Every Claim, we mean it.

“If there is an issue, Healthcare Horizons is going to find it.”

“Healthcare Horizons looks at issues that few other vendors address.”

Exceptional Communications

We know that audits are our business, not yours. We also know that you have a final responsibility to understand the process and make the decisions that result in the best ROI. Our detailed reports and interaction with our senior auditors mean you get the information you need in a way you can understand.

“Thank you for providing the updated report. I appreciate your efforts and commend you for your diligence and commitment to completing the task.”

Attention to Detail

With experienced auditors teaming with technology advances, we spot red flags that are often missed. We are familiar with errors stemming from human mistakes, systemic process fallacies and fraud. When you know what you’re looking for, you have a better chance of finding it!

“This has been the highest quality of audit performed on our behalf.”

Professionalism

We know that our clients are working with other professionals to administer their self-funded healthcare plans. When errors are found, it’s important to remember that everyone makes mistakes. The essential next step is to work with all parties to fix the problem and reimburse the company.

“Our experience has shown that we can trust Healthcare Horizons not to disrupt our relationship with our third-party administrator.”

Flexibility

Time is money and money is what keeps you in business. While our clients can be involved in the audit process as much or as little as they would like, most of them find that once they give Healthcare Horizons the go ahead, they can simply look forward to reports and receiving their returned dollars.

“We use Healthcare Horizons on an annual basis and are grateful for the minimal time commitment required on our part to monitor our plan.”

”I appreciate your flexibility in accommodating my schedule for a future discussion of the final report.”

“One reason we selected Healthcare Horizons was due to their timely responses and level of commitment.”

Our Commitment to You

We are thankful for our relationships with our clients. Some have become more than business acquaintances and are now friends. This happens as a direct result of our company philosophy.

“We will never lose sight of the fact that our clients are the very heart of our business, and that our success hinges upon theirs. This is why client satisfaction is a key focus of our company, and why we make outstanding service our top priority.”

If you are ready to make sure you are not overpaying on healthcare claims, we would be thankful for the opportunity to help. Contact us for a complimentary evaluation. 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.
Halloween witch hiding overpayment

Beware healthcare reimbursement overpayment: A Halloween horror story

Imagine if you will, an employee has surgery for a freak chainsaw accident. Assisting in the patient’s care are a masked surgeon, an anesthesiologist with a large wart on the nose, a post-op nurse (who happens to always have a broom with her) and administrative staff who appear to have dead eyes. The total cost for the procedure is $100,000. But unbeknownst to you, your third-party administrator paid out a total of $150,000. That’s $50,000 of overpayment lost to you and your company’s bottom line.

 

This story, while (possibly) fictional, is based on real-life billing errors. Healthcare reimbursement overpayment is a real and growing problem. In fact, according to a 2019 study by Humana, overpayments were a significant contributor toward the estimated $265 billion in wasted healthcare spending.

With a growing number of medical claims each year, there quite simply will be more mistakes. The 1-3% error rate doesn’t change so the numbers rise. There are several factors that can contribute to healthcare reimbursement overpayments. The type of mistakes include:

  • Coding errors: Coding errors can occur when healthcare providers use the wrong codes to bill for services. This can lead to overpayments for services that were not actually provided or for services that were provided at a lower level than what was billed.
  • Duplicate billing: Duplicate billing occurs when healthcare providers bill for the same service multiple times. This can happen accidentally or intentionally.
  • Fraud: Fraud is another leading cause of healthcare reimbursement overpayments. Fraud can involve healthcare providers billing for services that were never provided, falsifying medical records or upcoding services.

Turn an Overpayment from a Trick to a Treat

Medical claim overpayments can dress up as something innocent and if you don’t know what to look for, you won’t find the mistake. Fortunately, we are experts at unmasking the imposters. Our comprehensive review process means that we find more errors than the random sample method. Random may be okay when reaching in the candy bowl, but it means you could be missing a big reimbursement when reviewing your healthcare claim payouts! Don’t you want to find that missing $50,000?

Halloween is a time for fun and spooks, but it’s also a time to uncover the mistakes in your healthcare claims payments and make plans to try and keep them from happening again. Let us take the scary out of your self-funded health plan. We can help you with your audits and review your annual agreements to help protect your investment.

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.
man scratching head about unexplainable error

Identifying the Unexplainable in Health Insurance Claims

There are plenty of things to make us go “hmmm,” but health insurance payments shouldn’t be one of them! Our job, every day, is to identify mistakes in healthcare claims payments and occasionally we run across a case where there just doesn’t seem to be a logical explanation for an overpayment. In 99% of these unexplainable, head-scratching cases, they are one-off processing errors.

How Do Unexplainable Mistakes Happen?

Perhaps you’ve heard the expression, “garbage in, garbage out.” And guess what? Everyone makes mistakes. When we see overpayments where there doesn’t appear to be logical explanations, the most likely reason is human error. These typically show themselves in two areas.

  • Coding errors: Medical billing codes are used to describe the services provided to a patient. These codes are complex and can change frequently. Even small mistakes in coding can lead to inaccurate payments. These can be entered incorrectly due to lack of knowledge about a procedure or unfamiliarity with a system.
  • Data entry errors: These errors include the wrong patient information, incorrect dates of service or incorrect billing amounts. Sometimes a data entry error is simply a slip of the fingers. Think of when you’re typing an email or texting. When you’re quickly moving, you often won’t realize you had a typo before you hit send.

Getting Reimbursed from the Typo

Healthcare Horizons’ comprehensive, “every claim,” review process makes us successful at identifying these one-off errors. This approach yields improved results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, helping our clients correct the issue and recover the overpaid dollars. By going to great lengths to ensure that our medical audits are as thorough and accurate as possible, Healthcare Horizons has been able to recover millions of dollars in overpayments for our clients, as well as ensure long-term savings by correcting root-cause issues.

For a great example of a strange error, read our latest Lost Benjamins story! 

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.

Undisclosed Fees and Costs: The Bad and The Ugly

There is no GOOD hidden fee in your self-funded healthcare plan.

Ask questions are you aware of the hidden fees with check box for yes or no and pen hovering over the yes checkboxWe’re all familiar with hidden fees or undisclosed costs. We see the “extra charges” once we’re ready to check out on Ticketmaster, VRBO or any major airline, to name a few. These charges are so common that they really aren’t “hidden” anymore. We know they are coming.

Unfortunately, such fees in self-funded healthcare plans aren’t as easy to spot – and they can add up to significant dollars for both the self-funded employer and plan beneficiaries. Read more to learn what you should watch for in your plan agreement.

Expected Fees

The fees that self-funded employers typically monitor are administrative fees. These fees may be based on a percentage of total paid claims, or they may be calculated by a formula outlined in a plan agreement. No matter how calculated, you know these fees are a cost of having a third-party administrator (TPA) oversee your health plan operations.

Undisclosed Fees and Costs

These fees are the ones you don’t see coming.  A large employer recently filed a lawsuit against its health plan administrator claiming that the TPA has, for over a decade, wrongfully charged millions of dollars in undisclosed fees.  Some of the claims made in the lawsuit could be summarized as follows:

  1. Lack of due diligence. While timely payment of claims is expected and desired, when claims are paid “almost immediately, with no follow-up inquiry” mistakes are often made. These may be duplicate payments or overpayments. Either way, the self-funded employer is incurring costs that are not expected or justified.
  2. Cross-plan offsetting. If a claim is overpaid to a provider using funds from one client, it is alleged that a major TPA “corrects” this by deducting the overpayment from its next payment to the provider. While the net effect to the provider is appropriate reimbursement for services rendered, that next payment reduction is allegedly done without regard to which employer gets the benefit of the lower payment. These dollars should be credited to the employer that was charged the original overpayment.
  3. Use of repricing companies. When a TPA receives claims from out-of-network providers, it often engages a repricing company to negotiate lower payments to the provider. This practice should be outlined in the plan agreement and there should be transparency as to the repricing company used. In this litigation, the employer claims the TPA owns the company collecting payments for negotiating settlement amounts – an undisclosed conflict of interest and possible double-dipping.

Ways to Avoid Hidden Fees and Excess Costs

The most important thing you can do to avoid hidden or undisclosed fees in your employee health benefit plan is to ensure that you understand exactly what is in your plan agreement. When it is time to review and renew a plan agreement, consider the following:

  • Fees may vary depending on the TPA and the type of policy.
  • The fees may be waived or reduced under certain circumstances.
  • Ask about all fees upfront, including any arrangements with companies affiliated with your TPA. Don’t be afraid to ask that all fees be disclosed and fully explained.
  • Get quotes from multiple plan administrators. This is the best way to make sure that you’re getting the best deal.
  • Monitor and evaluate all charges or “cost savings fees” by your TPA under any “shared” cost-savings arrangements.  Such so-called savings may prove unfounded.
  • Understand the surcharges and reinsurance fees that may be associated with the plan. These fees can add up, so it’s important to be aware of them before you choose a plan.
  • Have a comprehensive audit performed annually by an independent company that has no conflicts of interest with any TPAs or insurance brokers.

Healthcare Horizons’ comprehensive medical claims audits identify overpaid claims and uncover hidden fees.  In addition, we offer complimentary reviews of your third-party administrative services agreement audit rights language to ensure you aren’t restricted to a random sample audit. Let us help you uncover hidden fees and undisclosed costs before they hit your bottom line.

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.
like many rabbits in a forest, systemic errors can multiply quickly

Systemic Errors Multiply Faster than Rabbits

Have you ever had rabbits in your yard? One or two may seem harmless, but left unchecked, they will quickly multiply and destroy your landscaping, garden and grass, leaving you with a big bill to fix the mess. Systemic errors in a self-funded health insurance plan work the same way. One error that costs your company $100 won’t impact the bottom line significantly. But that same $100 error, committed numerous times over an extended period, will cost your company a lot of money…sometimes even millions of dollars!

How Systemic Errors Occur

Self-funded health insurance plans are popular for businesses, specifically those with a large number of employees, because they can lower costs, provide more flexibility on coverage and include greater control over benefits. However, because of their scope, self-funded plans can be more susceptible to systemic errors.

Systemic errors are mistakes that occur in the underlying systems and processes of a plan. They can be caused by a variety of factors, including benefit plan setup errors, incorrect coding edits, abusive or fraudulent billing, inadequate processor training and outdated technology.

Some of the most common systemic errors in self-funded health insurance plans include:

  • Incorrect eligibility determinations, leading to employees being denied coverage or receiving incorrect benefits.
  • Inaccurate claims processing, resulting in delayed or denied payments, or in incorrect amounts being paid.
  • Fraud and abuse are intentional errors that occur when employees file fraudulent claims or providers bill for services that were not rendered.


The Fix for Errors is in Your Data

Employee complaints are one red flag that errors are occurring in your health insurance claims. Health insurance is an area that your employees need to trust will be accurate and available. When claims repeatedly are denied or employees must pay a larger than expected out-of-pocket share, there may be an unnoticed error in processing.

Finding those errors happens through a careful analysis of claims data sets. These reviews are done through audits. In our comprehensive audits, we work with you to audit your third-party administrator (TPA) and identify potentially incorrect claims. By analyzing complete data sets, and not just random samples, it is possible to identify patterns that suggest the presence of systemic errors (this also catches one-off errors!). For example, if a particular type of claim is consistently denied, this may indicate a code was incorrectly entered when the system process was set up. Once we flag suspicious claims, we collaborate with you – our client – to determine which claims to assess fully. Then we go to work to recover overpaid dollars and return them to you.

Systemic errors can be sneaky because when the error occurs it might not be noticed, either due to the smaller dollar amount error or confusion over medical claims language. This stealth behavior underscores the need for regular outside audits of your self-funded plan by experts. Only with regular reviews can you be sure that your plan is being administered correctly, employees are receiving their full benefits and your plan is not overpaying for care.

It’s time to get the rabbits under control. Contact Healthcare Horizons to begin managing your healthcare expenses with a comprehensive audit.

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.