Medical claims audits aren’t scary, but the results of not performing them can be frightening! Audits are best practices in the healthcare industry, especially for self-funded health plans. Comprehensive audits involve a thorough review of claims to ensure they are accurately paid on behalf of the self-insured client.
Still hesitant about conducting medical claims audits…
What’s the Worst That Could Happen?
- The Alien Abduction Claim: An employee submits a claim for medical expenses incurred during an alien abduction. The auditor, being a rational person, dismisses the claim as a prank. However, the employee insists that the aliens had performed a complex procedure and provides evidence in the form of a shiny metal implant.
- Time Traveling Employee: Imagine your employees submitting claims for tickets to the future or the past, citing “historical research” as the reason.
- The Ghostly Illness: An employee submits a claim for treatment of a mysterious illness that only manifests when the employee is alone at night. The auditor, unable to verify the claim, recommends a consultation with a paranormal investigator.
- Furry Family Members Submit Claims. Picture your employees submitting claims for their cat’s laser eye surgery or their dog’s dental cleanings.
Okay, so these scary scenarios are a bit far-fetched.
But the point is, finding errors in your medical claims ISN’T the worst thing that can happen. The WORST thing that can happen is that you DON’T find the errors – costing your company thousands, if not millions, of dollars. Addressing issues now can save money when the same error repeats year after year after year.
Why Audits Are Healthy – not Scary – for Self-Funded Plans
- Identifying Errors and Inefficiencies: Audits can help uncover errors or inefficiencies in your claims processing that may be costing your plan money. Healthcare Horizons’ comprehensive audits review every healthcare claim and specifically target claims to review onsite with the carrier, rather than a random selection. This approach yields much better results because we identify both isolated and systemic errors and assign actual dollar impact to those errors. By identifying these issues, you can take steps to correct them and prevent future losses.
- Ensuring Fiduciary Responsibility: Legal experts are sounding the alarm about growing compliance risks as more healthcare costs are funded by employee contributions. This raises the importance of protecting the fiduciary responsibilities of employers. We believe one of the most fundamental elements in corporate oversight is sadly lacking in healthcare benefits administration at many companies – effective audit policies and practices. Many self-insured companies fail to have an annual audit of paid medical claims. Our comprehensive audit provides assurance that companies and employees’ healthcare costs are not being inflated by payment errors and abusive claims.
- Improving Plan Performance: Following best practices in healthcare claims management ensures the plan matches client intent, provides oversight of the administrator to ensure accuracy, implements cost-containment measures achieved by correct payment processing and identifies areas to eliminate fraud, waste and abuse.
Healthcare Horizons can help you avoid common and hidden nightmares by providing a streamlined and efficient audit process. We also return overpaid dollars to your company bottom line. Don’t let fear or uncertainty hold you back. Contact us today to learn more about how we can help your self-funded health plan.
Curious about the types of discoveries we make in our audits? Check out our Lost Benjamins chronicles if you want to read something really scary!
