Podcast

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.

Medical Claims Audits Find More Than Money

What Medical Claims Audits Find

First, and most importantly, comprehensive medical claims audits WILL find overpaid dollars in healthcare claims. Is that all you need to know? Great! Click here to contact our office to schedule a consultation click here for medical claims audit information

But wait, there IS more! Reviewing all claims in comprehensive audits is only one way we identify potential cost savings errors in self-funded healthcare plans.

In the constantly changing healthcare environment, periodic audits are essential to help identify and correct patterns of overpayment. At Healthcare Horizons, we are committed to thoroughly reviewing all available data to ensure that our clients’ fiduciary obligations regarding healthcare payments are being met as accurately as possible. This results not only in the recovery of overpayments but also in the correction of root-cause issues to improve efficiency and generate long-term savings for our clients.

Based on this thorough review of data, we make recommendations to our clients after each audit to help contain costs going forward and protect their bottom line.

Three Common Audit Recommendations by Healthcare Horizons

1) Clients should consider negotiating enhanced audit rights in future administrative services agreements.

Healthcare Horizons always recommends that clients explore options for a more comprehensive, targeted audit of all future claims if the audits are currently limited in scope by their Administrative Services Only (ASO) agreements. If the ASO only allows for random sample audits, the chance of finding errors drops significantly. (Read this blog about the importance of equal fiscal protection for your company.)

2) Clients and their TPAs should agree upfront on how out-of-network charges will be handled.

Too often we see claims processed according to what the TPA believes the plan defines but catches the clients (and usually the employee) by surprise with an unexpected out-of-pocket payout. We recommend two key inclusions: a set agreement for the maximum allowed amount that will be paid on out-of-network claims and the ability to consider pricing options other than full-bill charges. A maximum limitation sometimes found in agreements is to cap the out-of-network payments at 125% of the Medicare amount. Healthcare Horizons also helps with out-of-network charge negotiations, specifically in helping to identify fair pricing strategies.

3) The Client and TPA should discuss plan intent for situations in which other primary coverage should pay as primary.

This occurs frequently with employees that are also eligible for Medicare. Once an employee or a former employee under COBRA turns 65, Medicare should provide the primary coverage for them. If the employer plan is secondary to Medicare under federal law, the plan will not pay benefits for services or supplies that are included within the scope of Medicare’s coverage. This occurs even if an employee fails to enroll in Medicare when eligible. In other words, if a participant is eligible for Medicare Part B benefits but does not enroll, the plan should pay as if the participant had enrolled in Medicare Part B. The plan would then pay any secondary coverage after the Medicare Part B estimation.

The ASO needs to include language that addresses Medicare Part B estimation requirements. This outlines how the TPA estimates what Medicare should pay for a particular claim. Then the TPA factors that estimate into determining what the employer plan will pay on the claim.

Medical Claims Audits Protect the Company

Not having medical claims audits as an annual must-do is like not reviewing your insurance coverage for five years or not balancing your checkbook (we think that is still a thing!). Only by having a full, comprehensive look at all medical claims are you able to determine if there has been an overpayment, misinterpretation of benefits, fraud and abuse, or systemic errors causing up to thousands of dollars of repeated Lost Benjamins. Self-Insured plan fiduciaries are responsible for making sure the healthcare plan is administered properly. Any errors or unexpected bills are the COMPANY’S responsibility to pay and sometimes fall to the employee. The good news is that you don’t have to leave that to chance. Let’s talk about what medical claims audits can find for you!

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

The Top Two Questions to Ask Your TPA

We talk a lot about WHY you should be getting external healthcare claims audits. (These statistics emphasize the importance.) So, in this article, we are going to assume you have made the excellent decision to have audits. Congratulations! But did you know that all audits aren’t created equal? Do not assume that your self-insured healthcare plan’s audit rights are covered by the TPAs standard language. These are the top two questions you need to ask your TPA to make sure you are not paying for a less-than-thorough audit.

1. Do you allow for full 100% comprehensive auditing, without restricting the audit to random sample selection?

TPAs are entrusted by clients to manage the claims and payments of the plan, but their money is not at stake – yours is. Your company deserves the same protection a TPA would require for their own fully-funded plan.

There are two primary types of audits: random sample and comprehensive. Insist on comprehensive audits.

The typical outdated methodology for medical claims auditing is random sample selection. In this type of audit, auditors randomly select 200-300 claims out of millions of transactions. Auditors examine those claims for errors based on predetermined criteria and extrapolate the results to determine a claims error percentage of the entire data set. This approach historically has been considered standard practice when handling a large number of claims, but it carries a high margin of error that can work against the company in three ways.

If the auditor encounters an error on a randomly selected sample claim, it is virtually impossible to determine if the error is isolated or systemic in nature.
It is likely that significant one-off errors exist outside of the random sample selection.
It is often difficult to convince payers to issue settlements based on the results of a random-sample audit.

We are different because of our comprehensive auditing process. We review every healthcare claim and Healthcare Horizons leadership submits a specifically targeted selection of claims to review onsite with the carrier. Our approach yields much better results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, making a much stronger case to the payer.

If you are settling for a random sample selection audit, you are throwing money away. Unfortunately, many TPAs only want to allow random sample selection audits. They know the likelihood of any error being found using this method is much smaller. When comprehensive audits look at every claim, data errors will be found. But finding mistakes is a GOOD THING – for you. Insist on comprehensive audits.

2. Do you limit the number of audits that can be performed?

Service agreement audit language may contain many stipulations. A common restriction is on the number of audits conducted over a set length of time. Much like restricting audits to random sample selection, restricting audit frequency significantly limits the potential for errors to be discovered. Therefore, your ability to recover overpaid dollars is also greatly reduced.

Service agreements should not limit the number of times you can request healthcare claims audits. We recommend annual audits, not every other year as many TPAs enforce. One of the reasons that annual audits are so important is that claim recoveries are subject to time limits. It is common for the service agreement language to restrict claims recovery to two years or less. Here is the basic problem: when audits are not performed each year, claims may be too old to recover.

For example, in 2022 we can look back at the 2021 claims dataset for errors. If the audit is not performed until 2023, these 2021 claims will be too old to recover. If you are not having regular audits and a claim falls out of the timeline eligible for review, you will be out the dollars overpaid.

For our largest clients, we may audit quarterly, but annual reviews protect self-funded companies and their employees from overpayments and out-of-pocket expenses. In addition, our auditors are there to improve processes by providing suggestions and identifying inconsistencies, which will help eliminate overpayments and systemic errors.

The Top Two Questions Make the Difference

Now you know the top two questions to ask your TPA to ensure you are receiving the fullest scope of audit rights. Your next step is to work with someone that understands your rights, can execute a comprehensive audit, and return the most money to your bottom line.

In our 23 years of providing comprehensive healthcare claims audits, we have seen virtually every benefit setup, provider contract method, and claims administration policy that one would expect on claims audits of the world’s largest self-insured employers. Because of this experience, we quickly assess gaps in the healthcare audit rights in your service agreement. We offer a free audit rights assessment to make sure the audit language in your service agreement is not limiting your ability to recover funds. It is YOUR data and, more importantly, YOUR money. Don’t leave it on the table!

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

3 Things Benefits Managers Told Us at SHRM

The SHRM conference in New Orleans this year was spectacular (ending the event with a Brad Paisley concert was icing on the cake!). It was wonderful talking with friends in the Human Resources world – in person – and meeting many benefits managers eager to find ways to contain costs in their employee benefits plans. In listening to these HR professionals, we learned three things:

Most benefits managers think their brokers or TPAs handle all the auditing of their healthcare plans.
Some were unaware that they should be reviewing audit rights in the ASO agreements.
All worry about how much work it would be for them to do an audit and how much stress it would cause them.

Don’t Assume Your TPA is Looking Out for You

Your third-party administrator is tasked with one job: to process your medical claims in the most efficient manner. As benefits managers for self-funded employers, you trust your TPA to process the healthcare claims correctly so that you are not overfunding healthcare payments.

Unfortunately, even though so much of the process is automated, humans are still involved in the process. And humans make mistakes. Mistakes fall into one of two broad categories: one-off or systemic. (You can see a more detailed breakdown of the types of errors in our recent blog: Mistakes happen. Ignoring them could cost you.)

One-off errors are mistakes that, once fixed, shouldn’t happen again. These can include transposing a number in the claim code or misspelling a patient’s name. But just because these are “simple” mistakes, don’t think the financial hit can’t be significant! (Here is one example.)

Systemic errors are embedded issues within the claims process. These mistakes can cost a company hundreds of thousands of dollars over time. Typically, these errors occur because a mistake was made in setting up the plan. Examples include claims being filed through a location instead of a provider (as in this example) or a treatment being capped at a certain amount due to being categorized as out-of-network, when it actually is in-network.

The TPA has little incentive to look for these errors and recover overpaid monies. Why – because they are paying with your money not theirs. While most TPAs are excellent at what they do and truly do want to process claims mistake-free, it’s impossible to do so at 100%. In fact, estimates show that up to 80% of claims data has an error. Not all of these errors have a financial impact, but many do. If your TPA, through your service agreement, is telling you they will perform an audit and that they guarantee a 98% success rate, you should ask for more details. Is the audit a random sample selection of claims for review? If so, it is highly likely they won’t randomly select the claim with the mistake. Are you willing to take that chance?

Your Company Does Not Have to Settle for the Standard Audit Language

In any negotiation, the first offer is probably not the best. The same is true for the audit rights language in most TPA service agreements. While the agreement says that you have audit protection, the language is typically very restrictive. For instance, does the agreement say that you cannot work with an outside audit firm? Make sure you are negotiating for comprehensive, independent audits. Not sure what to look for? Read this blog for tips. Additionally, we offer a no-cost audit language assessment to determine the effectiveness of the audit system in place for your company.

HealthCare Horizons Does the Work for Benefits Managers

HR professionals are busy. Our audit process involves you as much – or as little – as you want. Once you set the process in motion by giving us access to your medical claims data, we only need to involve you to decide which claims you would like to pursue for recovery. We provide clear communication on the impact the recovery will make (hint: it isn’t just the amount of dollars reimbursed!) and we will work with your TPA to move forward. If there is a systemic error, we will also explain in detail where the breakdown in the setup occurs so that your TPA can correct the problem.

As for stress? The only stress involved will be if you DON’T have regular comprehensive audits. Now that you know that there are most assuredly mistakes in your data set, the idea of losing money that could be returned to your company’s bottom line will cause sleepless nights.

The Only Bad Mistake is the One You Don’t Address

We say it often, not finding mistakes will do more long-term harm to your company, and potentially your credibility, than having an audit discover errors. Finding the claims errors and recovering dollars from overpaid medical claims means more money for your company’s bottom line. As the benefits manager, that is your responsibility. That money can go toward other valuable programs within your organization. Not to mention the money you save employees. Now you know. So now is the time. Contact us to start your medical claims audit. Cause the Effect.

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

Healthcare Claims Mistakes Happen. Ignoring Them Could Cost You.

“Accountability is the glue that ties commitment to the result.”
Bob Proctor

Are you worried that if claims mistakes are found in your healthcare data set that you will be held responsible? We hear this a lot, but the fact is, NOT finding the mistakes and leaving them uncorrected is what makes individuals or companies look bad.

Human Resources departments should continually find ways to conserve costs and ensure HR is a bottom-line contributor for the company. After payroll, employee benefits are the next biggest expense for a company. Keeping expenses manageable while still providing robust benefits is a delicate balancing act. In today’s job market, benefits are a must. But just because your company will fund healthcare plans for employees, it doesn’t mean the expense shouldn’t be held in check. Fortunately, finding the mistakes in medical billing records is a straightforward way to show accountability and return money to the company. That returned money is then available for other worthy company initiatives.

What happens if you don’t find the claims mistakes?

According to a report in Becker’s Hospital Review, as many as 80% of medical bills contain errors. As healthcare costs continue to rise, so does the need for healthcare payers to reduce overspending from avoidable billing errors and improper claims reimbursement.

As an example, let’s say medical claims errors occur in 10% of claims filed. If a self-funded company has a third-party administrator (TPA) processing more than $1 million in claims payments each year, this could mean $100,000 of overpaid claims, at a minimum!

“Given the sheer volume of claims submitted each day, capturing and reconciling discrepancies based off of claims data alone isn’t just ineffective — it’s flat-out unviable. Payment integrity systems that review claims data against medical records are helping payers identify potential waste and abuse with greater accuracy than ever before, uncovering immediate and long-term cost savings opportunities.”[1]

This is what Healthcare Horizons does through our comprehensive audit process. With comprehensive audits, the full data set of paid claims are reviewed for errors in claims payments. Many companies who realize that they should be auditing annually are still relying on random sample audits. Random sample audits are better than nothing, but Healthcare Horizons believes they are not sufficient to ensure adequate cost containment measures are in place for the plan. We find that random sample audits rarely find significant overpayments or systemic errors. Are you willing to settle for 90% accuracy? (Read more about why you shouldn’t settle).

What do claims audits find?

The root cause of our audit findings usually involves one of 5 types of errors. Often, we find more than one of these errors has led to overpayment of medical claims.

Systemic error. These are errors that may have occurred when the plan was established and typically involve charges that repeat.
Manual one-off error. The most common mistake, this is usually due to human error when inputting information.
Lack of action on retroactive information changes. Reviews are frequently performed to determine patient eligibility for certain procedures or claims. If the changes in eligibility are not entered into the system, incorrect charges or reimbursement requests will be submitted. These inaccurate claims result in erroneous denials or payments when compensation should not have been made.
Discrepancies in plan interpretation. Since humans interpret plan requirements, incorrect payments can happen if there are differences of opinion about what the plan covers.
Provider billing errors. This error is also typically human error. Transposing just one number can cause medical claims to be incorrectly coded and paid.

Implementing tools, like audits, to find these errors shows a high level of ownership and responsibility to ensure the best management of employee and company dollars.

Finding claims mistakes isn’t about pointing the finger.

We have uncovered many examples of systemic errors in claims processing that could cost a company millions of dollars in potential lost payments. Our case studies page outlines some of the most egregious examples of overpayments. Our comprehensive audits not only find the errors and allow the company to recover these overpayments, but we then work with the company and their TPA to fix the ongoing issue that caused the overpayments from the onset.

With the new CAA (Consolidated Appropriates Act) in place, plan fiduciaries have new sign-off responsibilities beginning in December of 2022. Comprehensive audits are a tool to ensure HR leaders and C-Suite management feel comfortable that the systems in place for processing the large number of healthcare claims are accurate, and include a way to fix errors…including the fees you may not know existed. As the plan owner, you have the final responsibility for these costs. So, the question left to ask is: Would you rather find the mistakes in your healthcare claims data, or would you rather someone discover the error down the road when it is potentially too late to recover overpayments? You can be the hero. We help make sure you are protecting the financial integrity of your employer-provided and funded healthcare plan.

We will be at SHRM in New Orleans next month and would love to talk about the systems you have in place and how we can help with your financial bottom line. Stop by Booth #2870 for a giveaway and we will be happy to answer your audit questions!

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