Podcast

Top 10 Medical Claims Audit Questions

We know comprehensive medical claims audits are the best way to protect your company’s self-funded health insurance investment. We also know that the claims audit process can seem intimidating. But it doesn’t have to be! Here are some of the most common questions we are asked. We would love to talk with you about claims audits and how we can help you return overpaid dollars to your bottom line.

1.     What type of medical claims audit should we choose?

You have two options for audits: random sample and comprehensive (also called Targeted or Focused). We perform comprehensive audits, where 100% of your claims data is analyzed, because we know that random sample audit findings are the luck of the draw. Unfortunately, your administrative services only agreement (ASO) may limit you to random sample audits. Random-sample audits are better than not performing an audit at all; however, random-sample audits can leave thousands of dollars behind. We can help you evaluate your audit rights at no charge to make sure you have access to the most effective audit available.

2.     How much does a comprehensive audit cost?

Our customized, flexible pricing options are designed to meet your needs and accommodate your TPA requirements. Our fixed-fee pricing ensures you know exactly what your out-the-door audit cost will be and is most often covered by the recovered dollars. We also offer a risk-free, contingency pricing structure that is based on what we collect, not on the errors we identify.

3.     How much money can I expect to have returned from each audit?

It is difficult to estimate a rate of recovery, but on average .5%-1% of the total annual medical spend is returned. Recovery amounts depend on several factors including:

  • The amount of the overall claim
  • The number of claims an ASO allows to be analyzed
  • The age of the claim (most ASOs won’t allow recoveries of claims older than 12-18 months, which means annual audits are a must!)

4.     How much time do I need to set aside for the audit?

While we welcome any involvement in the audit process from our clients, the time commitment of the client is minimal. The client must review and sign the contract and Business Associate Agreement, provide plan documents and once the audit is complete – review the audit report. Below is helpful information a client can provide to enable us to ensure the best pricing.

  • Client Name
  • The Third-party administrator (TPA) processing claims
  • Total annual medical spend
  • How many subscribers/members on the plan
  • Number of plan designs offered (HDHP, PPO, etc)
  • Audit rights (Comprehensive 100% audits rights versus random sample selection; fixed fee pricing versus contingency pricing)

5.     What communication can I expect during the audit process?

We will send updates to your company’s point of contact throughout the audit process. These check-ins include:

  • Proposal that outlines our audit process, categories of testing, and projected cost
  • Preliminary findings of the initial review
  • Final audit report that includes dollars associated with recoveries, our final audit comments in response to the TPA, and recommendations on best practices
  • Any post-audit communications we receive from the TPA on the recovery process

There is no time limit on our availability post-audit. We are happy to answer any questions.

6.     How long does an audit take?

Audits typically take 4-6 months to complete. The length of an audit is largely dependent upon receipt of viable data, the TPA timeline for preparation of the audit and scheduling the virtual site visit. (POTENTIALLY INSERT TIMELINE GRAPHIC – YES that would be good here)

7.     Are there any performance guarantees?

We do not offer performance guarantees, which often do not represent true success. Our commitment to our clients is to continually look for ways to do what we do better. Accuracy is important in our business. We are constantly refining our data mining process to find every error possible to yield higher recuperations for our clients. We believe that our long-standing relationship with numerous clients is a testament to our performance and accountability.

8.     What experience does Healthcare Horizons have in our industry?

Healthcare Horizons has been exclusively performing healthcare claims audits for self-insured employers for the past 24 years. We perform audits for companies in a multitude of industries, but our process remains the same no matter the industry of our clients. This breadth of experience across many different employers, industries, and claims administrators allows us to bring industry best practices to each project. It also provides us with the benefit of having seen almost every benefit setup, provider contract method, and claims administration policy that one would expect on a claims audit.

9.     How do you work with our TPA? Will performing an audit negatively impact our TPA relationship?

Third-party administrators are partners in helping recover as many overpaid dollars as possible. The TPA works with Healthcare Horizons to provide the medical claims data set, provide necessary reports surrounding the targeted sample selection and engages in dialogue concerning findings. Since audits should be an included provision in an ASO, the TPA expects that you will uphold your fiduciary responsibility to ensure the best management of your health insurance plan investment.

10. How do you ensure privacy and compliance mandates are met?

While sponsors of non-Federal government health plans may elect to exclude certain categories or plans for privacy reasons, doing so can impact findings and monetary returns. We understand that data integrity and security are top priorities and so we maintain exceptional administrative, technical, and physical safeguards to protect the confidentiality, integrity, and accessibility of protected health information consistent with the requirements of HIPAA policies.

Don’t let unanswered questions halt your medical claims audit.

Medical claims audits are valuable resources to protect one of the biggest expenses in your business. We are happy to review the audit rights language in your administrative services agreement at no charge to help determine the correct audit approach for your company, as well as make suggestions for future negotiations with your TPA. Don’t pay more in claims than you are required to pay! Get your questions answered and start the audit process today!

Are you going to be at SHRM 2024? Call us at 800-646-9987 to schedule a meeting or visit us at booth 1557 to ask your audit questions and enter to win a unique prize!

 

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.
Ticking Clock in a field

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.
money in a green hat

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

luck of the rainbow to a pot of goldRandom 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!

megaphone announcing healthcare horizonsAttention 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.
20220outlook for healthcare trends

2022 Healthcare Benefit Outlook

It’s that time of year. Time for the annual reflections on the past year and predictions for the next. While you might think there isn’t much change when it comes to employee benefits and healthcare trends, the past two years have proven to be full of surprises. So, we’ll look at the highlights from 2021 and then explore what we see as the 2022 healthcare benefit outlook.

Healthcare benefits outlook for 2022

The Impact of the Pandemic

2021 highlighted the negative impact of the Covid-19 pandemic in the workplace. Employers had to analyze nearly every aspect of their work culture, and that included employee wellness. Out of these reviews, clear trends emerged. Women experience more burnout than their male counterparts.  Mental health issues were up across the board as people struggled with work and home worries. Remote work exploded, adding new issues for human resources, cybersecurity teams, and the home-work balance. However, as the saying goes, necessity is the mother of invention. (1)

The Healthcare Benefit Outlook

According to new research by LinkedIn, the top three things Americans value most in their career now are work-life balance (34%), compensation (32%) and benefits (26%).

When you hear ‘employee benefits,’ the first two things that jump to mind are probably paid leave and healthcare coverage. With the Covid-19 pandemic stretching into year two, these are still the top “wants” from employees. However, we’re also seeing companies offer a larger variety of perks and solutions to attract and retain strong teams.

Some of these non-traditional benefits include hybrid work options, mental health benefits, more personal time off (with less stipulation for how the time can be used), and financial planning assistance. Yet, the biggest changes are likely to be seen in how healthcare is provided and funded.

Healthcare Benefit Coverage

At its core, the pandemic was a health care crisis. The panic and uncertainty that evolved from sickness, fear, or loss of income emphasize the importance of investing in comprehensive healthcare benefits for employees. Insurance brokers and human resource benefit managers need to keep this insecurity in mind as future benefits are structured.

Flexibility is Key

Gone are the days of one-size-fits-all plans. More personalized healthcare coverage is expected to grow over the next year. Employees realize they may need, or want, different levels of care than their co-workers. This is not surprising when almost every area of our lives, from how we stream television to our GPS, is customized. The areas listed should be explored to provide the best comprehensive coverage for individuals and families. (2)

  1. Personalized coverage. Each insured member should be able to choose the best care and price-point for their needs. This is actually a win-win for employees and employers. For example, when set up from the onset, people who first use lower-cost interventions see lower prices, if or when their care escalates. This rewards high-value care decisions that can make employee populations healthier in the long run.
  2. Personalized cost-sharing. Most employers provide an equal level of coverage for all employees. But that approach isn’t personalized. In fact, it can contribute to coverage inequity and perpetuate health care disparities. For example, consider two employees who have a $3,000 deductible on their employer-sponsored health plan, receive the same subsidy from their employer, and are eligible for the same level of coverage. To many, this sounds fair, but if one of them earns $30,000 a year and the other earns $300,000, their ability to access coverage is very different—and that is inequitable.
  3. Personalized experience. We can’t forget about opportunities to personalize care navigation and support experiences. People want to feel seen and heard. It’s important that employees have access to a broad network of high-quality, low-cost providers who speak their language, understand their culture, sexual orientation, gender identity, etc.—and they need help finding these providers.

Healthcare Benefit Outlook Incentivizes Utilization

Data shows 15% of Americans with employer-sponsored health insurance deferred some care between March and September 2020.

This statistic foreshadows both short and long-term implications for not prioritizing preventative care, which catches small health concerns before they become costly more serious issues.

“For years, we’ve used deductibles and copays to manage utilization and minimize cost increases in the hope that individuals would become better educated and make better health care decisions with some financial skin in the game. However, even before the pandemic, it was becoming clear that this didn’t work, but rather caused employees to defer and even skip preventative care altogether. And now, as preventative care utilization tanked during the pandemic, employers will increasingly see the costly, long-term effects of offering plans that don’t incentivize receiving care early and often.” (3)

Employees need to know their options and be able to access the care they need, when and where they need it. This will improve health, reduce high-cost claims, provide a return on the investment of the resources and costs, and deliver a health program with value for all employees.

What Does This Mean for HR & Insurance Brokers?

The status quo is changing. It’s not what it was 3 years ago and it likely won’t be the same at the end of 2022. First, it’s up to you to provide employee healthcare benefit options to clients that meet the needs of both employee and employer. You can achieve these goals during enrollment season:

  • Find plans that remove barriers to employees accessing care
  • Ensure the plans offered have uncomplicated user experiences so that confusion does not become a deterrent to use

Second, since we all know that prices aren’t likely to come back down – especially in healthcare – identifying cost savings for benefits is imperative.

Finding cost savings to provide exceptional benefits

We want to help you provide the best overall employee benefits in 2022 and beyond. Addressing overpayments in one of your largest budget line items is a great first step. But you first must know what your data says. Then you can look for ways to reduce overpaying on healthcare claims. Dollars can then be reallocated toward other company initiatives or help keep healthcare costs from rising.

Our “every claim” audits find the errors in data sets – and they are there! Some may be one-time mistakes, but others may be systemic issues causing repeated overpayment and loss of dollars. We are experienced in identifying both.

It is also important that your medical claims are being processed according to your plan design and intent. In our audits, we review your claims according to the unique benefits detailed in your medical plans to ensure those benefits are being administered correctly.  If not, these types of processing errors could continue to reoccur and add up to significant overpayments.

2022 will be full of challenges with new legislation for transparency and rising costs. However, we saw perseverance and out-of-the-box thinking this past year that gives us hope in regard to the healthcare benefit outlook. We would welcome the opportunity to partner with you in providing a cost-efficient experience for your company or clients.

Sources:
(1) https://www.benefitspro.com/2021/12/07/progress-report-how-far-have-employee-benefits-come-in-2021/
(2) https://www.benefitspro.com/2021/11/16/personalized-health-benefits-are-the-future/
(3) https://www.benefitspro.com/2021/11/16/3-benefits-trends-to-consider-for-a-post-pandemic-workforce/
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.
Analyzing healthcare budgets and finding errors with audits

Budgets and Healthcare Audits: A Smart Partnership

When you are preparing a company budget, are you including healthcare audits? Budgets and healthcare audits are both necessary pieces for fiduciary responsibility. Failure to audit could be a red flag that you haven’t protected the financial interests of your employees & employer.

budget and audits present money as gift
Healthcare audits return YOUR money back to your budget.

What’s at stake?

    • Employers pay an average of 86% of healthcare premiums for single coverage and 72% for family coverage.
    • Health insurance costs approximately $2.64 per hour for private industry workers.
    • In 2020, the average annual premiums for employer-sponsored (self-insured) health insurance were $7,470 for individual plans and $21,342 for family coverage.

Source: SanaBenefits

Obviously, this is a significant portion of a company’s budget. Healthcare costs are expected to continue to rise, so company leaders must find cost savings while still providing competitive, quality care for their employees.

Protecting Employer and Employee

Simply, healthcare claims audits find errors. And if your company is providing healthcare, there are errors in your claims. Your healthcare budget, and your employees’ healthcare expenses, can be contained with regular audits.

In a successful comprehensive audit, you will recover overpayments and identify potential systemic issues causing the incorrect billing. Both are important.

Overpayment of Healthcare Claims

Recovering funds is the most important step for both employer and employee. If claims are overpaid, the employer will see more expenditures in individual claims, but also potentially be quoted for higher premiums at the next negotiation period.

For employees, claim overpayments can negatively impact employees’ deductibles and co-insurance payments. Look at the following example.

An employee had gall bladder surgery in an in-network surgery center. A primary and an assistant surgeon performed the surgery. Assistant surgeons are generally priced at 20% of the full schedule rate. However, this assistant surgeon was out-of-network and billed more than $20,000 for the surgery. Since the assistant surgeon was paid at full billed charges, the patient ended up paying more for their co-insurance than they would have paid if the assistant surgeon had been paid according to the applicable fee schedule. The employee did not have any other medical claims for the year, but unfortunately still reached their out-of-pocket maximum due to this claim processing error and was out more than $3,800.

Systemic Errors in Healthcare Billing

Systemic errors are different than data entry errors. With systemic errors, there is a process in place that is causing repeated errors in billing. Eliminating these root cause problems should reduce the number of claim errors you have in the future.

For example:

A facility may be unbundling charges that are meant to be billed as one item. Unbundling is when providers charge for line items individually instead of using a code that bundles charges. By unbundling the provider gets paid more than they should had the correct bundled code been used.

Have you met your fiduciary responsibilities by including audits in your company budget?

If the answer is no, contact us. “Health plans have a fiduciary responsibility to their members to make certain that the members’ claims are processed and paid correctly,” says Barry Silver, Healthcare Horizons Senior Vice President. “Otherwise, their employees could end up paying more money than they should on medical bills. The plans can engage external auditors to review the medical claims payments to assess if their claims process is functioning properly and that their claims are being paid as accurately as possible.”

Our unique audit process will help you return the maximum dollars to your bottom line. If your budget is already set for next year, an audit is still important because it will give you a strong comparison of your healthcare expenses so that you can strategically plan going forward. It really is never too late to take charge of your company’s healthcare expenses.

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.
money blowing

Healthcare Audits: We do the work, You save the money

Healthcare audits are the best way to ensure cost containment of health insurance plans. But we know that the last thing you want to do as a human resource manager or insurance broker – especially after open enrollment – is deal with the details of healthcare audits.

Good news! We do the work so you don’t have to! But what good are healthcare audits if all the mistakes aren’t found?

As many as 1 in 10 healthcare claims have errors.

Our Process

Random sample audits simply can’t find all the potential errors. We go beyond the random sample audit with our 100% claim audit approach. This may sound labor intensive, but don’t let that scare you off! Our process is time-consuming because it is thorough. But our audit professionals will do the heavy lifting.

  1. We sit down with clients after a contract is signed and talk through their goals. This, and providing us with your plan documents, is the majority of your time investment in the process. While we will always update you on findings and give you the opportunity to accept or decline next steps, you aren’t involved in the review of the claims. A member of our leadership team is involved with your audit from beginning to end.
  2. We use computer software to help analyze and identify patterns, but we don’t rely on just these algorithms. Our experts have been reviewing claims for a long time – some have been with our company for decades! In that time, they have developed an eye for red flags. This allows us to look for potential systemic errors as well as the one-off errors that occur in claims payment processing.
  3. TPA relationships are respected. Having an independent agency perform audits is prudent, and we know that your TPA is not the enemy. Mistakes happen. We work with your TPA to identify errors, monitor collections, and help negotiate direct credits or settlements.

What do you have to lose?

If you are the human resources benefits manager for a self-funded insurance plan, you know that keeping healthcare costs in check is important to not only employees but also your employer.

If you are the insurance broker, you can provide more value-add to the client by recommending audit services. You have an opportunity to show your client a significant recovery on overpaid claims so why wouldn’t you? Read our blog on the benefits of audit services for brokers and then reach out for a consultation.

Healthcare Horizons is the most people-centered, trusted healthcare claims audit firm in the nation, focusing exclusively on self-insured employers. To learn more about our audit difference, contact us at 800-646-9987.

Best ROI for 4 Hours Time
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com. 
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.
Businessman putting a card with text ADD VALUE TO YOUR CUSTOMERS in the pocket

Brokers: 4 Claim Audit Benefits for Self-Insured Clients

Providing Value-Add to Clients

Claim audit service is an extra benefit for brokers to present to clients. Audit services can save clients big money over time. There are 4 significant advantages to brokers who include a claim audit service in their proposed recommendations.

  1. Healthcare is the largest expense for self-insured employers. They should feel confident that their money is being spent correctly. A broker is held to a high standard by clients to provide the best cost-saving options for their employee plan. Audits ensure that the TPA is held to the same standard.
  2. When audits save clients money, they are more likely to be repeat customers. Potential new clients will then want to know what methods are being used to contain costs and keep premiums in check.
  3. Audits can identify systemic problems with claim processing. If problems are uncovered and not corrected, the broker has the opportunity to suggest different services and vendors.
  4. Analyzing audit findings can reveal trends that allow improvement to RFP questionnaires. Thoughtful RFPs then allow the broker to make the best recommendations for healthcare plans.

Healthcare Horizons’ claim audits are guaranteed to impact at least one, and probably all four, of the benefits listed above. We analyze every claim, not just a small sample of claims, and work with clients to make recommendations for cost-savings opportunities they may be missing in their plan set-up. We not only identify overpaid claims that can be recovered but also discover potential systemic problems that lead to overpayment trends. Recommending claim audit options to your client is a win-win for you and them.

Limiting Audits

August is an important month for TPA negotiations. As brokers move forward to find the best third-party administrator for their self-insured clients, they must be aware of language in the services agreements that may limit the client’s rights to audit claims and recover overpayments.

A hurdle in many new administrative service agreements is a restriction limiting the ability of self-insured clients to have an audit of all claims in their data set.

Why is it important for audits to be freely accessible by self-fund clients?

  • While TPAs will commit to some form of internal auditing, they restrict external auditors from conducting comprehensive auditing. This is a conflict of interest. Outside auditors are unbiased and can be used whenever a client feels it’s necessary.
  • Few TPAs will conduct internal audits as a part of the contract. Usually, there is an additional cost to perform the audit. Depending on payment structure, outside auditors can perform contingency-based audits where the self-insured client only pays fees after an overpaid claim is recovered.
  • Audits conducted on a yearly basis avoid the possibility of claims being unrecoverable. A common eighteen-month to two-year limitation on claim recovery is written in many TPA agreements.

Healthcare Horizons offers a free review of administrative service agreements to ensure that a client’s rights to audits are protected.

five benefits of brokers working with healthcare horizons on claim audit
If you are a broker, stop by SHRM Booth 5079 or contact us directly to talk about the different ways we can help make you a savings hero in your client’s eyes!

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Best ROI for Four Hours Work
To learn more about our approach to healthcare claims auditing or out-of-network provider fee negotiation services, visit Healthcare Horizons, or reach out to us at hhadmin@healthcarehorizons.com. 
Randy King is president of Healthcare Horizons Consulting Group, Inc. The company is one of the nation’s leading healthcare claims auditing firms, focused exclusively on self-insured employers since 1999. Healthcare Horizons has recovered millions of dollars for its clients through auditing and air ambulance negotiations for some of the world’s largest employers.
don't shortchange employees circle image

How to Maximize Healthcare Cost Containment

*This article has been updated to include new information.*

Helping Human Resource Leaders become Healthcare Heroes!

At the upcoming Society of Human Resource Management (SHRM) conference, Healthcare Horizons will meet with hundreds of individuals tasked with ensuring that a company’s health insurance benefit is a viable option for their employees, without sacrificing coverage to reduce cost. The #SHRM21 theme was “Now More than Ever… It’s time for HR to step up and deliver.” The #SHRM22 theme “Cause the Effect” continues this idea that what HR does impacts every single aspect of a company and its bottom line. Healthcare Horizons helps human resource leaders maximize the cost containment of healthcare claims, allowing funds that would normally be spent on overpayments to be used for other worthy company initiatives.

Benefits are the #1 employee perk
According to GlassDoor, 57% of new hires cited benefits, and specifically health insurance, as a leading factor in their final decision to accept a job.

What does this mean for healthcare administration?

Human Resource departments play a part in many initiatives for a company, all designed to improve employee welfare and support company goals. One goal of the HR benefits manager is to provide healthcare benefits at the best possible cost, for both the employer and the employee.

Since healthcare is one of a company’s largest expenses, cost-containment is critical. Unfortunately, medical claims errors happen routinely in healthcare. Audits are vital to uncovering these errors and recovering funds. This process protects both the company and the employees.

Self-insured employers can lose millions of dollars each year in incorrectly paid medical claims. These errors drive the cost of insurance programs up, costing the employer and, consequently, the employee more.

Every time a claim is overpaid, an employee’s coverage is impacted. This may show up immediately through paying more out-of-pocket dollars toward a deductible. Or the impact may not be noticed until the next year when they see an increase in co-pays, deductibles, or premiums. From an HR perspective, this leads to unhappy employees.

charts showing rising cost of healthcare due to claim errors
Systemic errors in healthcare claim processing cost employers & employees money. Audits catch the mistakes!

How can we help with cost containment?

Performing regular healthcare audits benefits both the employer and the employee. “Every claims data set contains errors.  People aren’t perfect, mistakes happen,” says Beverly Healey, Operations Manager for Healthcare Horizons, and SHRM21 attendee. “Healthcare Horizons audit processes work with your third-party administrator to not only uncover incorrect billing but also to identify systemic issues that may be costing the employers thousands, even millions, over time.”

To learn more about how HR leaders can improve a company’s healthcare bottom line, stop by SHRM Booth #2870 or contact us directly.

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The Difference is in Knowing.
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.
The moment you realize your TPA overpaid millions in healthcare claims.

Benefits Blues: The Moment You Realize Your Benefits Manager Has Some “Splaining” to Do
are you asking your tpa the right questions
The moment you realize your TPA overpaid millions in healthcare claims.

Are self-insured CEOs asking the right questions of their benefits managers when it comes to healthcare spending?  Do they even know that there are crucial questions to be asked?

Every year, millions of dollars in overpaid healthcare claims are funded in error by self-insured employers. Asking the right questions can help ensure that those dollars paid in error can be recovered and returned to an organization’s bottom line.

What are the right questions self-insured employers should be asking?

  • Who audits our claims payer (TPA)?
    As a self-insured employer, the TPA processing your claims is paying out your money, after all. Who will find the financial errors that can range, on average, from 1 to 3 percent of your total claims, a cost that self-insured employers are funding from their own pockets? Internal audit processes typically review a few high-dollar or randomly selected claims. It is nearly impossible for random sample audits to uncover systemic issues that can lead to future errors in claims payments. Best practices call for third party audits of your healthcare claims, not the broker (who does not specialize in comprehensive claims auditing) and not the TPA (who has no financial incentive to ensure payments are correct).
  • Why aren’t we auditing every claim versus a random sample?
    The administrative services agreement between the self-insured employer and their payer often limits the scope of healthcare claims audits.  Payers often limit the audit ability of the employer to only random sample audits.  Employers should demand the right to review 100% of their claims payments.  Random sample auditing will not uncover all of the errors that are potentially present, which can leave hundreds of thousands of recoverable dollars on the table. Benefits managers can and should renegotiate contracts so the employer’s financial interests are protected. It’s your fiduciary responsibility to your stakeholders.
  • How are your benefits managers helping you avoid surprise bills?
    When your employee seeks medical care, if he or she inadvertently uses an out-of-network provider, the financial impact can be significant to both employer and employee. This often happens in the case of air ambulance services. A hospital or emergency crew may call for air transport, and the patient has no choice of a service provider. Later, the self-insured employer and the employee are hit with staggering  “surprise bills.” Does your benefits manager have a process in place for negotiating with providers like air ambulance services to ensure that bills are fair?

Regular audits and negotiation of high-dollar out-of-network fees by a trusted company like Healthcare Horizons can help self-insured employers contain costs and return formerly “lost” dollars to their bottom lines. Cure the Benefits Blues by performing an annual, 100% Difference comprehensive audit on healthcare claims, which can uncover thousands of dollars (or more) that can be recovered for the self-funded employer.

The Difference is in Knowing.

To learn more about our approach to healthcare claims auditing or provider fee negotiation services, visit Healthcare Horizons or contact us at hhadmin@healthcarehorizons.com.

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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.