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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benefit plan setup errors, incorrect coding edits, abusive or fraudulent billing, inadequate processor training and outdated technology.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.

Relying on Luck Can Cost a Self-Funded Company Millions

It’s fun to search for four-leaf clovers in the hopes of finding unexpected luck. But if you rely on wishes and leprechauns to keep self-funded healthcare expenses in check, your luck is going to run out.

Each year businesses lose millions of dollars from incorrectly paid medical claims. Even the best benefits administrators don’t always catch the mistakes – they don’t have the time to scrutinize millions of claims. Thankfully, there is a solution.

Healthcare claims audits analyze the paid claims data sets and look for overpaid dollars on medical claims. When incorrect payments are found, dollars can be recovered for a company. There are two kinds of audits: random sampling and comprehensive. Which do you think gives you the best “luck” in recovering the most dollars?

How Random Luck Can Cost You Money

Random sample audits are just that – completely random. Software generates the sample claims based on a dollar range. For example, if 250 claims can be reviewed during a site visit, the random selection process would involve five dollar range strata with 50 claims from each. Would you really want to select 50 claims in the $0 – $500 range when you may have overpaid claims in the million-dollar range? And what if the random generator doesn’t choose one of those million dollars claims that were paid in error? Your chances of recovering that money are only slightly better than finding a pot of gold!

Are you willing to hope and wish that all your errors have been identified through a random selection? With random sample audits, you are relying on luck that overpayments, including the largest errors, will be identified.

Comprehensive Healthcare Claims Audits Put Luck on Your Side

You can make your own luck by ensuring comprehensive claims audits are performed on your data. Opting for a comprehensive audit allows skilled individuals to inspect the entire data set, run hundreds of queries for likely errors and complete a site visit with claims that have been identified as a probable error.

Computer software may not discern anything unusual about a claim that paid a provider for five surgeries, on the same person and on the same day, but an experienced auditor will realize that the pattern is incorrect.

Finally, auditors work with the client to decide which claims to recover or in the case of member impact, negotiate a settlement with the TPA for the overpayment. TPAs will then recoup overpayments back to the client or issue a settlement to the client for the overpaid claims.

Your Self-Funded Plan Deserves More

Benefits managers are tasked with finding a health plan that is cost-effective for both the employer and its employees. Proactively negotiating the terms of the administrative services only agreement can protect the financial interests of both. In order to attain cost savings for the plan, a random sample approach is not optimal. We offer a complimentary review of your administrative agreement to make sure there isn’t language limiting your ability to audit healthcare claims and recover overpayments.

Take luck out of the equation. Insist on comprehensive audit rights and partner with a company that has expert auditors to recover the maximum dollars!

Attention SALGBA members! We’re going to be joining you at the conference in New Orleans next month! We’d love to become a trusted partner with you as you build alliances and identify resources to better administer benefits plans for employees. Stop by Booth 214 to learn about how we have recovered millions of Lost Benjamins for state and local governments.

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.

Heart Care Funding is Not Just for February

February is Heart Health Awareness month, but heart care should be a focus every month! Heart disease is the leading cause of death in America according to the Centers for Disease Control. Its impact is costly to all Americans and businesses and deserves appropriate funding.

Some quick facts:

Heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States.
One person dies every 34 seconds in the United States from cardiovascular disease.
About 697,000 people in the United States died from heart disease in 2020—that is 1 in every 5 deaths.
In the United States, someone has a heart attack every 40 seconds.

The financial impact is even more startling: heart disease cost the United States about $229 billion yearly from 2017 to 2018.

The consequence of this benefit not being available is not only a lack of quality heart care but also the possibility that good employees will leave for jobs that do provide healthcare benefits.

Finding Funds for Heart Care

Comprehensive heart care isn’t just treating acute incidents, like a heart attack, but includes cardiac therapies, medications and ongoing monitoring. Health insurance is a lifeline for millions of Americans suffering from heart disease. A substantial number of these individuals rely on their employers to provide coverage. Without this employee benefit, many people suffering from heart disease – or trying to prevent it – cannot get the comprehensive care they to protect their heart. For self-funded companies, healthcare is a substantial budget line-item.

What if your company could fund benefits without taxing the bottom line?

Ensuring that a healthcare plan is not overpaying for medical claims is one way to earmark funds for better heart and healthcare programs. There are two ways to avoid overpaying for heart-related medical claims: make sure they don’t happen in the first place and recover overpaid dollars if they do.

Preventative Programs for Heart Care

Many programs are in place to help promote healthier living and mitigate the negative outcomes of heart disease. However, these programs – to be fully effective – have a cost associated with them. Yet, the costs of preventative care programs can be outweighed by the savings of not having to fund high-dollar, intensive treatments. For instance, having an annual fitness benefit in a health insurance plan encourages individuals to exercise more, which is good for the heart and can help prevent high blood pressure. Another example is implementing a regular wellness check requirement. These annual risk assessments, when completed, not only reduce premiums for employees but also discover any issues in the early stages, allowing for less expensive interventions to be used before major, more expensive, complications arise.

Conduct Regular Comprehensive Audits to Recover Overpayments

Each year millions of dollars are overpaid on healthcare claims that are inaccurate. Consequences of these overpayments include:

Paying more toward plan maximums than required, and thereby reducing the number of claims that may be covered, if not in this plan year, then in the next
Increased administrative fees for self-funded employers, with the costs passed on to employees in the form of increased premiums or reduced benefits
Higher out-of-pocket costs for employees

Mistakes happen. In fact, up to one out of every three medical claim submissions has an error. It is the fiduciary responsibility of the entity providing health insurance (for self-funded companies, that’s YOU!) to ensure that the dollars spent are providing the services promised. Fortunately, human resources managers or employee benefits advisors have a powerful tool to help oversee this requirement: comprehensive claims audits. During a full audit, analysts review every claim for errors and assign red flags to those claims that seem illogical. These may be one-off mistakes (typically human input errors) or systemic errors that allow mistakes to repeat themselves, often snowballing and costing companies sometimes millions of dollars in overpayments. Having an annual comprehensive audit increases the likelihood of recovering these overpaid claims and correcting any systemic issues due to errors.

Not Overspending on Healthcare is Good for Everyone’s Heart.

Make a commitment to heart care this month and put in safeguards that will protect your company’s fiscal health and your employees’ health all year long. You can cover both ends of the saying, “An ounce of prevention is worth a pound of cure.” Work with health care insurance providers to implement preventative programs, but when you do have to fund bigger treatments, make sure you aren’t overpaying for the procedure!

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.

“Winner” of Our Lost Benjamins Award and how to avoid being on the list

The Winner is – Clients that Found Benjamins!

Our new biggest loser competition – the Lost Benjamins Award – hit the ground running in 2022. Drum roll please…our 2022 winner is Man Glows After Hundreds of X-Rays on Same Day. It seems everyone agrees that not noticing a bill for 850 x-rays on the same knee on the same day is a mistake that shouldn’t happen. Fortunately, our comprehensive audit didn’t miss it and we were able to recover thousands of dollars for our client.

A close second was our largest recovery to date – a $1.7 million error! This was a classic case of failed checks and balances. Human error caused the mistake, but the backup – a review of the processed claim by an experienced employee – missed the overcharge. Thankfully, we didn’t! That number of Benjamins can help fund a lot of other worthy employee initiatives!

Payment Integrity Makes Sure Your Company Isn’t Our Next Winner

Most of the errors found in claims datasets are not intentional, but the rapidly changing healthcare system often makes accuracy a challenge for today’s workforce.

As staffing shortages impact every level of healthcare, including billing staff, medical coders and data entry specialists, steps need to be taken to minimize mistakes in the medical claims process. A payment integrity plan helps identify areas of weakness, correct problems and reduce the risk of future errors.

The payment integrity plan should encompass every phase of the billing cycle. This includes a review at the entry point to ensure common sense billing. Our Lost Benjamin Award winner above is the perfect illustration of the importance of starting the claim correctly! The next stage checks to be sure there isn’t fraud and to confirm medical necessity. Finally, the system should include an end-stage comprehensive review of claims. This is the last stop for finding errors and recovering overspent dollars.

Comprehensive Reviews are a Win-Win

Unfortunately, these winners are only a handful of the types of mistakes our audits catch on a regular basis. Are your audits finding these costly errors? If you are unsure, contact us for an assessment of your audit process. Our comprehensive reviews help control medical costs – and that’s a win for both the self-insured employer and their employees!

Thank you to everyone that submitted entries and voted in our first annual LBA contest. Don’t forget to check back each month to read about our latest Lost Benjamins nominees for 2023!

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.

insurance savings with medical claims audits

End Each Year with Big Savings on Healthcare Claims

Finding Savings for Your Bottom Line Has No Season

While the end of the year is the time many people evaluate their personal and professional finances, saving money isn’t limited to a calendar date. However, particularly in business, end-of-year financial reviews set the stage for the upcoming budget process. If your company is self-insured, reviewing your employee healthcare plan costs to identify savings should be your number one priority – after all, your company benefits are the second greatest expense behind only employee salaries.

Healthcare Claims Audits are Important for More than Just Savings

The cost of healthcare in the United States is staggering. Health insurance expenditures totaled $3.6 TRILLION in 2018. If you’re one of the 99% of large firms that provide employee health insurance, you’re paying a big part of this tab! There is no indication that this number won’t continue to rise – in fact, some estimates show costs increasing year-over-year by at least 10%. Reviewing the amount paid out against your company’s policy is vital to insuring that neither the company nor the employees are overpaying.

Each year benefits and human resources managers face the important – yet tiring – task of renegotiating health insurance benefits for their self-funded company. What if this year, you were prepared to negotiate for a service that directly impacts your company bottom line by finding big savings? Comprehensive healthcare claims audits are a tool to help you find dollars that can be returned to your company budget. Additionally, these audits ensure you are meeting fiduciary requirements mandated to all insurance providers through the CAA or Consolidated Appropriations Act.

Comprehensive Audits vs Random Sampling

Much like you trust your doctor to run annual blood tests to look for underlying health problems, you can also trust a qualified auditor to review your medical claims each year. These consistent reviews will show inconsistencies, data entry errors and systemic faults in your claims processing. BUT it’s not wise to leave this process to chance. You don’t ask a doctor to only look at your triglyceride counts instead of a full cholesterol panel and you shouldn’t settle for looking at only a portion of the filed claims.

As many as one in ten medical claims have errors! Imagine that you only review five percent of your claims. How can you be expected to recover all of the overpaid dollars? If you only do a random sample audit, you are betting a lot of money that your audit will land on one of the mistakes in your data set. A better option is a comprehensive audit. Our process looks at every claim and identifies those that potentially have errors. Once identified, we work with you – our client – to determine which claims should be pursued for recovery. The best part is that we do all the work and you get the savings!

Recovered Money is the Gift that Keeps on Giving

Everyone has a wish list, especially this time of year. Businesses are no different. Employee benefits are important to attract new hires and for retaining team members. However, they all come at a cost. For every dollar overspent on a healthcare claim from your self-funded policy, that is a dollar lost that could be used for another program. To ensure you aren’t erroneously lining the pockets of a healthcare entity instead of funding initiatives in your business, insist that your TPA include comprehensive medical claims audits in your service agreement. The investment in time (as little as four hours) and money (you pay when we recover) will deliver the best ROI for your company’s bottom line. That is something to celebrate all year!

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers, involving all national and most regional payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.

Grateful Season

November ushers in two things: the grateful season and a flurry of year-end activity. We are thankful for many things this past year, all of which have a part in helping shape portions of the healthcare industry into a more accurate and less wasteful system.

The return to in-person events, from conferences like SHRM to leadership presentations, allowed us to reconnect with new and old friends.
We saw new legislation that made the healthcare industry more transparent, better protecting all participants, including
- the “No Surprises” bill that ensures consumers know how much procedures will cost and
  eliminates balance billing for out-of-network ambulance service, and
- the mandated inclusion of fees paid to suppliers and conduits so that employers can
  objectively evaluate the best healthcare plan for their situation.
Our team has worked exceptionally hard to provide even better service to our expanding client base.
Partners, like benefits brokers and human resources managers, have been supportive of our initiatives and acted as true ambassadors to decision-makers to see the importance and value of medical claims audits.

And of course, we are most thankful for our clients. The relationships we develop through our unique comprehensive audit process allow us to interact with so many wonderful individuals and companies. These relationships make our job more rewarding and allow us to provide even better results because of the belief in our system.

Grateful but Busy

While we would all like to slow down for the holiday season and simply count our blessings, the end of the year also means deadlines. From a healthcare perspective, patients are trying to squeeze in last-minute appointments to use any benefits that expire on December 31. Most practitioners are doing their best to accommodate as many people as possible. However, increased volume and tight deadlines are a bad combination and can lead to administrative errors. It is important to have a review process in place to ensure the claims made through a healthcare plan are filed accurately. Specifically, medical claims audits can find overpayments that can save an employer-funded plan thousands of dollars. (For an overview of how overpayments impact both a company and the employees, read more here.)

Another deadline to be aware of as it pertains to healthcare claims is the statute of limitations for evaluating claims and seeking reimbursement for any overpayment. Most plans have a set time frame for claims to be reviewed, often 18 or 24 months. Most claims reviewed outside of this limit will not be eligible for corrective action. So, if many more claims are filed leading up to December 31, the deadline for reviewing a large number of claims is also coming up. If between one and three percent of claims under normal circumstances have inaccuracies, that is a significant number of potential overpaid claims and corresponding dollars that your self-funded healthcare plan could miss recovering.

We wish everyone a season of gratitude. We hope you enjoy time with family and friends, count many blessings, and rejuvenate for the upcoming new year. As you look forward to next year, we welcome the opportunity to help your company provide better benefits for employees through medical claims cost savings. That is something everyone would be grateful to see!

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers, involving all national and most regional payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.

Why Your Budget Needs to Include Audits

Have you ever gotten a notice saying that you might have unclaimed money from a refund, settlement, or inheritance? What was your first reaction? Most people think about what they would do with this “surprise” windfall. But guess what? It was always your money! You just didn’t know it was missing. It’s time to put it back in your budget!

As the 2^nd biggest expense for most self-funded companies, healthcare plan line items should be an area of particular focus. In medical claims audits, we find errors 100% of the time through our comprehensive audits. Simply, if audits are not in your annual budget, you are throwing away YOUR money. Including a comprehensive medical claims audit in your annual budget is money well spent. It’s like the old adage: you have to spend money to make money.

Cost Containment Protects the Company Budget

Including comprehensive audits in the annual budget is a proactive cost containment strategy. With healthcare costs rising each year, and more high-value claims filed and paid by self-funded plans, it is no longer enough to assume your third-party administrator can catch every error.

The numbers tell the story. Each year, Americans file 232 MILLION healthcare claims!

Even if only 1% of the claims are incorrect, that is more than two million mistakes! In fact, the industry average is almost 3% in errors. Put a low average dollar amount of $1000 to every mistake and plans could be overpaying healthcare claims by more than TWO BILLION dollars!

Here are some examples of how ignoring mistakes in data claims would have cost companies thousands of Lost Benjamins but were thankfully caught through a comprehensive audit.

High-Value Claims are a Leading Cause of Error

In data compiled prior to the Covid-19 pandemic (2019 compared to 2015), high-value claims increased by double-digit percentages. (Information below summarized by Stop Loss Insurance Brokers.) These costs lead to higher premiums for the insurer and higher out-of-pocket expenses for the insured.

In 2019, 7 out of every 100,000 employees had a claim exceeding $500,000, up from 37.1 in 2015. That’s a four-year increase of 82 percent and an average annual percentage increase of 13 percent.
9 out of every 100,000 employees had a claim exceeding $750,000, up from 13.8 in 2015. That’s a four-year increase of 66 percent and an average annual percentage increase of 10 percent.
Eleven out of every 100,000 employees had a claim exceeding $1 million, up from 6.3 people. That is a four-year increase of 75 percent and an average annual percentage increase of 8 percent.
3 out of every 100,000 employees had a claim exceeding $2 million, up from 1.0 in 2015, a four-year increase of 130 percent, and an average annual percentage increase of 21 percent.

Our comprehensive audit system analyzes every claim. Our trained experts spot inconsistent trends in claims data, which occur in all claims, but have bigger negative repercussions the larger the claim amount. While a high-value claim on its own isn’t going to automatically have errors, the ones that do exist cost companies and employees deeply. Identifying these claims, particularly the systemic errors that occur when numerous claims are being made for one illness, saves companies thousands, and sometimes millions, in reclaimed overpaid dollars.

Comprehensive Audits Protect Your Budget and Bottom Line

Overpaid dollars, through inaccurately filed claims, can cost your healthcare plan thousands of dollars. Using our unique 100% difference auditing process, we find these errors and flag them for recovery. Incorrect claims impact not only the current claim but also the affordability of your plan. When it is time to renew your policy, the amount paid out is a key factor in determining your policy price. You do not want to pay for incorrect claims that falsely inflate the payout number.

So, back to our original question: How would you spend dollars that you suddenly weren’t spending on healthcare? With the money you save by including medical claims audits in your annual budget, you have options for your company. You might fund:

Additional training
Raises
Employee appreciation programs
Technology upgrades
THE LIST IS ENDLESS!

Remember, the provider of a healthcare plan (that’s YOU, the employer) is responsible for errors in medical payments. It is your fiduciary responsibility to ensure that claims are not overpaid and that your company’s bottom line stays healthy. We can help. Contact us now to talk about the cost and savings you can expect by performing a comprehensive audit so that you can include it in next year’s budget.

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Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers, involving all national and most regional payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.