Podcast

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

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.

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.

We’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:

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.
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.
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.

How to SAVE Money While on Vacation

“Forgetting” a $20 bill in your winter coat pocket is not an effective way to save money! A wiser approach is to proactively fund your goals. And the same is true for your self-funded healthcare plans. Hoping money simply appears doesn’t cut it! To find ways to expand benefits to your employees, you must prioritize funding and identify savings. What if we told you that you could be getting a head start on savings while enjoying your vacation? Sound too good to be true? Read on!

5 Ways to Save Money for Vacation – or Other Life Events

Planning ahead is the number one way to save money – whether in your personal life or in business. You may want to save for a vacation or a family milestone, or you may recognize that you need to save for unexpected expenses, like medical bills. Here are five tips to help you save for your rainy-day fund. These same tips will also help you protect your company’s bottom line. (Be sure to read the last one!)

1. Record your expenses. The first step to saving money is figuring out how much you spend. This includes the big payouts, as well as the everyday items that add up.

Personal: Use an app like Mint to track your cash and credit card expenses. You can then sort by categories to see where your money is going each month.

Business: The same principle applies, but the input is typically manual into a program like QuickBooks or your company’s accounting system. The key is to make sure that all expenditures are logged correctly.

2. Include saving in your budget. Once you have an idea of how much it costs to run your household or your business, it’s important to set aside savings in your budget.

Personal: A popular budgeting approach is the envelope or bucket method. With this strategy, you place a designated amount of income into specific buckets. Savings should be a proactive bucket, not filled with leftover dollars.

Business: Some companies call this investment capital, others refer to it as a reserve fund. Either way, it’s important to ensure that a set amount of money is set aside for future needs. This needs to be a line item in the budget to avoid “funding bleed.”

3. Find ways to cut spending. This one seems obvious, but we rarely spend money on things we don’t think are important. Instead of eliminating a line item, look for ways to reduce the expenditure.

Personal: Eat out one to two times less each week or prepare your daily coffee at home. Looking for something bigger? Check to see if refinancing your mortgage would save money.

Business: Are there fees you are paying on bank accounts that could be waived? What about credit card processing fees? It’s important to review these charges that can quickly add up month over month. Always be on the lookout for those areas of overspending.

4. Make saving automatic.

Personal: With direct deposit, this is easier than ever! Send a percentage of your paycheck to different accounts. If a portion goes directly to savings, you won’t count on it to pay expenses. Plus, the compounding interest will help the nest egg grow!

Business: While there are more hoops to jump through, you can earmark certain funds to reserve.

5. Pick the right tools. This one is our favorite! And it’s probably the most important!

Personal: There are hundreds of online options to help you track and manage your expenses. You can receive alerts if you are nearing the budget cap you set for a certain category. Or you can install an app that will scan your bills for recurring payments, allowing you to unsubscribe for services you no longer need. The possibilities are almost endless – and fun!

Business: Mistakes happen – and in business those mistakes can be big and very costly. The most expensive area is your self-funded healthcare plan. Reviewing this plan annually is critical. If mistakes are made on your medical claims, your company could be losing thousands of dollars. A comprehensive audit will uncover these mistakes and work to recover YOUR money. Those recovered dollars could help fund the priorities you identified earlier.

We can help make sure overpaid claims errors aren’t eating into your budget. While you’re enjoying your much-deserved vacation, let us audit your plan. While the recovered dollars we find can’t fund your personal vacation, the money will benefit everyone in your company!

Source: Better Money Habits

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.

Spring cleaning is important at home, in the yard and in a health plan

Spring Cleaning Your Health Plan is Especially Important This Year

When we think of spring cleaning, we think of sweeping under the rugs, airing out the house, and washing windows. Doing these annual tasks not only helps us enjoy the warmer and sunnier weather, but it also helps clear out stale and musty air – which is good for our health.

You know what else is good for your health? A solid health insurance plan. If you are responsible for managing your company’s self-funded plan, spring is also the perfect time to check behind the curtains and shine a light on the corners of your plan.

Spring Cleaning Check List

Every year you should evaluate your self-funded healthcare plan. Your review should include the following:

Benefit utilization. Are your employees using the benefits in the plan? Don’t pay for something with little value.
Provider availability. Are employees able to access a large enough network of providers under any tier plan you offer?
Cost. If your plan cost has increased substantially, examine why and see if there are alternatives. Are there a small number of employees driving costs higher for everyone? A separate plan may make more sense for them.
Claims. A large part of the cost in your plan is obviously the payout of claims. We spend a lot of time talking about why you should have an annual comprehensive medical claims audit – and for good reason. If you don’t know where you are losing money, you can’t recover those lost dollars and you can’t fix the systemic issues. (Read a previous blog here.)

Finally, you should familiarize yourself with new government regulations and how that impacts you as a fiduciary. In 2023, this is even more important!

Plan for the Expiration of the Public Health Emergency

The ERISA legislation mandates that employers (or plan administrators) have fiduciary responsibility for the health coverage they provide for employees. The regulations and compliance requirements change often and “not knowing” isn’t an excuse for inadequate representation. One of the biggest compliance challenges over the past three years was implementing Covid-19 care. On May 11, the Public Health Emergency ended. This means that payer systems will need to be modified to change the paying structure for Covid testing and services, for COBRA extension enrollment that will be ending, and more.

Some key things to note:

The declaration of the Public Health Emergency defined the period during which plans must pay for Covid-19 diagnostic tests and related services without cost-sharing, as well as other items.

The National Emergency (which also ended on May 11) oversees dates and requirements for COBRA, special enrollment, and claims and appeals.

Oftentimes, charges for procedures due to end once health emergencies are lifted continue to be billed as a covered expense to plans, which means the plan and the self-funding entity overpay for services. Good auditors will find these overpayments in the data. Following are some of the more common provisions that sunset from plans 60 days after the end of the emergency:

Covering Covid-19 tests without cost-sharing
Over-the-counter Covid-19 testing
Coverage of preventive services and vaccines in and out-of-network by non-grandfathered plans
Expanded telehealth offerings to those not eligible for group health plan coverage
Ability to waive certain wellness standards related to Covid

Hire Help to See Things More Clearly

Just like spring cleaning your home can be overwhelming, partnering with professionals can help – you can clean up your healthcare plan and shine a light on misappropriated funds and ensure that your plan has implemented all necessary changes with the end of the national health emergency. The best way to do this is with an annual medical claims audit. We are different because we work in partnership with you and speak with your TPA on your behalf.

Our audits are:

Comprehensive. Settling for a random sampling audit guarantees you will miss finding claims errors. The error may be a $25 overpayment, or it may be $150,000. Are you willing to take that chance?
Timesaving. You simply don’t have time to review all the data in your paid claims data set. Our process evaluates each claim and identifies those that are likely to contain errors. You can be as involved as you’d like in the process, but all we really need is a small amount of time upfront to coordinate plan documentation.
Client-driven. Once we identify the claims that are agreed as overpayments, you choose the ones you’d like to pursue for recovery as some recoveries have member impact. Additionally, we offer customized, flexible pricing options designed to meet your needs and accommodate your TPA requirements. The return is more recovered dollars for your bottom line.

There’s never any time like the present to begin your spring cleaning, including reviewing audit rights, auditing paid claims and ensuring your plan is set up how you intended. We offer a complimentary review of your audit rights to ensure that you can review all your paid claims. After all, it’s your data!

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.

Your Wake-Up Call

It is important that human resources leadership and corporate counsels be mindful of the growing efforts by disgruntled employees and employee advocacy groups to utilize ERISA regulations to initiate class-action lawsuits related to alleged failures to appropriately manage medical costs. Motivated by the escalating impact on employees and their families from annual increases in health insurance premiums, deductibles, co-insurance, and other cost-sharing obligations, legal actions are being pursued. These actions may target both self-insured employers and their third-party administrators (TPA’s). Horror stories abound.

No Surprises Act Requires Follow Up

Healthcare Horizons continues to find various overpayments, including systemic issues, that if reported in a legal complaint would appear quite egregious, including out-of-network surprise bills being paid 100% of billed charges. The No Surprises Act went into effect in January 2022 and established processes to address egregious out-of-network claims, including arbitration if necessary. As we have reported many times in our Lost Benjamins Award materials, overcharges and overpayments adversely impact employers and employees.

A recent study reported that employees contributed 22% of their health plan’s premium costs in 2021. As medical cost-sharing provisions continue to rise, resulting in employees paying greater out-of-pocket expenses, as much as 15-25% of an employee’s annual compensation may be consumed by healthcare expenses. Thus, it should be no surprise there is a growing focus on the integrity of such obligations. This environment has the attention of plaintiffs’ attorneys willing to pursue class-action lawsuits on a contingency basis.

Comprehensive Audit Meets Fiduciary Minimum Standard of Care

If an employer has not had an audit performed by an independent expert, it may face allegations of failing to meet a fiduciary’s minimum standard of care. Reliance on the employer’s insurance broker or TPA to meet this obligation may prove unfounded. If any audits are performed, they most likely are random sample audits on all plans, not a single employer’s plan. Such audits miss over 90% of overpayment amounts and can miss systemic errors readily detected by 100% claims audits.

Human resource leaders should act immediately to ensure their company does not remain exposed to this increasing risk. Engage a qualified expert to perform a 100% audit of medical claims.

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.