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!

 

globe with world celebration lights in background

A World Full of Celebrations

Winter celebrations are as diverse as the world we live in. While some revel in festive gatherings, others cherish quiet moments with loved ones. No matter how you choose to celebrate, this time of year is a time to come together with loved ones, to make special memories and to cherish the bonds we share.

Whether you light candles to celebrate Hanukkah, exchange gifts under the Christmas tree, seek enlightenment during Bohdi Day, honor African heritage through Kwanzaa, embrace the ancient traditions of the Yule Festival, or any of the traditions that you hold dear, Healthcare Horizons wishes you a joyful season. As always, our mission throughout the year is to protect the privacy of our clients and their employees, recognize our staff and clients as our most important assets, and uphold the highest ethical standards.

In the world of healthcare auditing, where numbers reign supreme, we strive to never forget that there are real people behind the data. Every claim is an individual struggling with the complexities of healthcare or an employer wrestling with the rising costs of providing health insurance. These are the faces behind the numbers, the human stories that drive our commitment to excellence. No matter what the differences are in our society, at Healthcare Horizons we remain committed to providing our clients with the same unwavering level of service and acting in your best interest. We are grateful for the opportunity to serve you and to help you navigate the complexities of healthcare auditing.

Together, let us embrace the diversity that enriches our lives and celebrate the spirit of winter, a season that reminds us of the enduring beauty of the human spirit and the simple joys that bring us together.

All types of people…all types of celebrations…all types of claims…but one same wish: finding those moments that create lasting memories.

Happy Holidays from our house to yours!

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through our 100% Difference model and recovering millions of dollars for clients’ bottom lines while upholding the highest ethical standards. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for our customers.
woman with eyes closed clasping hands and smiling

Thankful Thoughts from Our Clients

A twine circles the word thankful

For nearly thirty years we have had the opportunity to work with a wonderful group of clients in multiple industries across the country. We are thankful for their confidence in our services, and we are equally thankful and humbled by their words of appreciation. Read below for a sampling of the kind affirmation we have received.

Why Our Clients are Thankful for Us

Thoroughness

Our comprehensive claims review means that we find more errors than random sample audits do – returning more dollars to our clients. When we say Every Claim, we mean it.

“If there is an issue, Healthcare Horizons is going to find it.”

“Healthcare Horizons looks at issues that few other vendors address.”

Exceptional Communications

We know that audits are our business, not yours. We also know that you have a final responsibility to understand the process and make the decisions that result in the best ROI. Our detailed reports and interaction with our senior auditors mean you get the information you need in a way you can understand.

“Thank you for providing the updated report. I appreciate your efforts and commend you for your diligence and commitment to completing the task.”

Attention to Detail

With experienced auditors teaming with technology advances, we spot red flags that are often missed. We are familiar with errors stemming from human mistakes, systemic process fallacies and fraud. When you know what you’re looking for, you have a better chance of finding it!

“This has been the highest quality of audit performed on our behalf.”

Professionalism

We know that our clients are working with other professionals to administer their self-funded healthcare plans. When errors are found, it’s important to remember that everyone makes mistakes. The essential next step is to work with all parties to fix the problem and reimburse the company.

“Our experience has shown that we can trust Healthcare Horizons not to disrupt our relationship with our third-party administrator.”

Flexibility

Time is money and money is what keeps you in business. While our clients can be involved in the audit process as much or as little as they would like, most of them find that once they give Healthcare Horizons the go ahead, they can simply look forward to reports and receiving their returned dollars.

“We use Healthcare Horizons on an annual basis and are grateful for the minimal time commitment required on our part to monitor our plan.”

”I appreciate your flexibility in accommodating my schedule for a future discussion of the final report.”

“One reason we selected Healthcare Horizons was due to their timely responses and level of commitment.”

Our Commitment to You

We are thankful for our relationships with our clients. Some have become more than business acquaintances and are now friends. This happens as a direct result of our company philosophy.

“We will never lose sight of the fact that our clients are the very heart of our business, and that our success hinges upon theirs. This is why client satisfaction is a key focus of our company, and why we make outstanding service our top priority.”

If you are ready to make sure you are not overpaying on healthcare claims, we would be thankful for the opportunity to help. Contact us for a complimentary evaluation. 800-646-9987

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through our 100% Difference model and recovering millions of dollars for clients’ bottom lines while upholding the highest ethical standards. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for our customers.
man scratching head about unexplainable error

Identifying the Unexplainable in Health Insurance Claims

There are plenty of things to make us go “hmmm,” but health insurance payments shouldn’t be one of them! Our job, every day, is to identify mistakes in healthcare claims payments and occasionally we run across a case where there just doesn’t seem to be a logical explanation for an overpayment. In 99% of these unexplainable, head-scratching cases, they are one-off processing errors.

How Do Unexplainable Mistakes Happen?

Perhaps you’ve heard the expression, “garbage in, garbage out.” And guess what? Everyone makes mistakes. When we see overpayments where there doesn’t appear to be logical explanations, the most likely reason is human error. These typically show themselves in two areas.

  • Coding errors: Medical billing codes are used to describe the services provided to a patient. These codes are complex and can change frequently. Even small mistakes in coding can lead to inaccurate payments. These can be entered incorrectly due to lack of knowledge about a procedure or unfamiliarity with a system.
  • Data entry errors: These errors include the wrong patient information, incorrect dates of service or incorrect billing amounts. Sometimes a data entry error is simply a slip of the fingers. Think of when you’re typing an email or texting. When you’re quickly moving, you often won’t realize you had a typo before you hit send.

Getting Reimbursed from the Typo

Healthcare Horizons’ comprehensive, “every claim,” review process makes us successful at identifying these one-off errors. This approach yields improved results because we identify both isolated and systemic errors and assign actual dollar impact to those errors, helping our clients correct the issue and recover the overpaid dollars. By going to great lengths to ensure that our medical audits are as thorough and accurate as possible, Healthcare Horizons has been able to recover millions of dollars in overpayments for our clients, as well as ensure long-term savings by correcting root-cause issues.

For a great example of a strange error, read our latest Lost Benjamins story! 

Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through our 100% Difference model and recovering millions of dollars for clients’ bottom lines while upholding the highest ethical standards. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for our customers.
Spring cleaning is important at home, in the yard and in a health plan

Spring Cleaning Your Health Plan is Especially Important This Year

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

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

Spring Cleaning Check List

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

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

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

Plan for the Expiration of the Public Health Emergency

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

Some key things to note:

  • The declaration of the Public Health Emergency defined the period during which plans must pay for Covid-19 diagnostic tests and related services without cost-sharing, as well as other items.
  • The National Emergency (which also ended on May 11) oversees dates and requirements for COBRA, special enrollment, and claims and appeals.

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

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

Hire Help to See Things More Clearly

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

Our audits are:

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

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

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

Tax Day: Double-Check the Details

If you’re like us, before taxes are submitted you will double-check the details several times. It’s smart to give the return one more review to make sure nothing was missed. If it’s important to review your personal finances, isn’t it equally important to review your business’s financial health?

Audits Find Errors

In our business, we all too often see healthcare plans that never receive the benefit of another review. Self-insured employers trust third-party administrators to process and pay claims that are consistent with the plan details and are error-free. In many cases, there is no incentive for the TPA to identify and correct errors. Make sure your agreement allows for audits. It is your money!

Double-Check your Audit is Comprehensive

don't gamble double-check your audits
Photo by Conor Ogle

Does your healthcare service agreement allow for comprehensive audits to find errors and recover funds? Even when a random sample audit is conducted, the odds are against you that it will land on a claim filed in error. Additionally, there is no way to find and resolve systemic issues to prevent future claims paid in error.

That is why we are so passionate about comprehensive claims audits. We want our clients to have the peace of mind that comes with knowing that every claim has been reviewed and that every systemic issue has been corrected. Please contact us to discuss a claims audit for your plan.

*This blog was originally posted 4/18/2106 and has been updated.

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.
looking at green dollar sign with magnifying glass

Healthcare Claims Audits: Are you auditing?

Your company needs to be conducting annual healthcare claims audits. YES, you are entitled to claims audits! Healthcare claims are one of the biggest expenses for companies that self-fund their employee healthcare plans. How do you ensure you are not overspending on claims?

Employer Healthcare Costs are Rising

Healthcare costs, to no one’s surprise, have continued to rise. This includes costs for services, costs to employers, and costs to individuals. While companies are picking up a large percent of the bill each year through premiums, the employees are seeing higher out-of-pocket costs, both in payroll deductions and overall deductibles.

Healthcare Claims Audits can help save employees money and keep deductibles from rising.
Average Annual Deductible for Employer-Sponsored Health Insurance Plans
Source: Statista.com

Healthcare claims audits help keep spending under control by finding overpayments and recovering funds. Then, that money can be used to retain the current benefit level or be invested in other company initiatives.

Employers cover about 70% of health-insured workers in the United States.

Employees still cite health insurance as the most desired benefit in the workplace. This benefit is usually the biggest cost outside of salary for employers.

Key Fact:

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!

A few more quick stats:

  • In 2020, the total direct written premiums totaled almost $825 billion. This was an 11% increase over 2019.
  • The average single-employee coverage cost to an employee was more than $7,000.
  • Employers cover the largest share of worker health insurance premiums, averaging about 30% of family premiums and 18% for single coverage. (Source: balancingeverything.com)

Don’t you want to know that your contribution is being managed properly? Healthcare claims audits are the way you can help control the financial integrity of your investment.

Why Healthcare Claims Audits?

Each year, 232 MILLION healthcare claims are filed in the United States.

Even if only 1% of the claims are incorrectly filed, that is more than 2 million mistakes. In fact, the industry average is almost 3% in errors. Unbelievably, this is considered acceptable. The truth is that mistakes are going to happen, but you CAN control the impact on your company with consistent healthcare claims audits. Two outcomes are likely. Both results protect your investment and return dollars to your budget for other uses.

  1. The audit finds overpayments & recoveries are returned to the company.
  2. If the audit is more than a random sample audit and instead analyzes every claim, the audit also finds systemic errors in the claims process. These findings allow solutions to be implemented so the same errors do not continue to cost your company money in the future.

What Do Healthcare Claims Audits Find?

Your healthcare claims are data sets. Trends are discovered based on a complete analysis of data. Once these trends are identified, policies can be reviewed and revamped as needed. This is not unique to healthcare claims audits. But, what is unique is that self-funding companies often do not know that they are in control of this data, not a third-party administrator (TPA).

You own this data. We can’t emphasize this enough. While TPAs often include basic audits in their service agreements, they are not financially motivated to ensure complete accuracy. Yet, not performing an audit can cost a company hundreds of thousands of dollars in overpaid claims. We are seeing more and more service agreements with language that is limiting a company’s right to audit all their paid claims and even discouraging outside audits. Do not sign agreements with this clause in place! TPAs are not our adversary. Rather, we work with them to save you – the main stakeholder – the most money. We do the work – so you don’t have to!

Key Fact:

Healthcare fraud costs the United States nearly $6 BILLION a year. Thankfully, most mistakes aren’t fraud. But when fraud does occur, it can mean substantial losses. Audits find the legitimate mistakes and the fraudulent claims.

Best ROI for Hours of Your Time

HR managers, benefits managers, and insurance brokers are already stretched thin. We get it! Our audit process lets you choose how involved you want to be in the process. If you only have a few hours to dedicate to exploring your audit options, that’s all we need. Once you’ve identified any specific issues and provided plan documents, we do the rest.

So, now that you know healthcare claims audits are an option, don’t wait. Start saving your company and employees money today! For more information on how our “every claim” audit is different, please read our blog “We do the work, you save the money.” Contact us directly at 800-646-9987 or online.

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.

 

The Last Days of Summer and Planning Ahead

End the summer right with responsible fiscal planningLabor Day has come to symbolize the official end of summer, with family gatherings, final trips to the beach, and the wafting aroma of BBQ on the grill. It’s also a time to start thinking about fiscal planning for the next year.

Labor Day began as a yearly, national tribute to the contributions workers had made to the strength, prosperity, and well-being of our country. The first observance was celebrated in New York in 1882, followed by a festival for the recreation and amusement of the workers and their families. Summertime has a way of reminding us that friends and family are what truly matter in this life.

Relationships are important, and at Healthcare Horizons, we believe in people and relationships first. Our focus this Labor Day, and every day, is on you, those who help make you successful, and your company’s financial interest. As you look ahead to year-end planning activities such as closing financial books, budgeting and creating goals for the coming fiscal year, let us contribute to your bottom line in 2018.

Healthcare Horizons helps keep your healthcare costs in check. It is crucial that self-insured employers conduct annual healthcare claims audits because one of the unintended consequences of self-insuring is that claims payers have no financial incentive to control costs. Regular healthcare claims audits ensure that employers are:

  • Fulfilling their fiduciary responsibility
  • Not overpaying claims or paying claims in error
  • Identifying and eliminating systemic errors
  • Recovering overpayments within the TPA’s timing limitations, typically two years

We offer customized, flexible pricing options 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. We also offer a risk-free, contingency pricing structure that is based on what we collect, not on the errors we identify.

Call or contact us today to get started on your fiscal planning for next year. We’ll do the work so you can sit back, relax, and enjoy the last days of summer.

April Industry News

April News Wrap Up

SIAA Announces National Conference and Expo http://www.siia.org/i4a/pages/index.cfm?pageID=6336

Medicare to Cut Payments to Employer Sponsored Advantage Plans http://www.modernhealthcare.com/article/20160222/NEWS/160229986/medicare-to-cut-payments-to-employer-sponsored-advantage-plans

Will the Anthem Express Scripts Battle Change the PBM Landscape? http://www.modernhealthcare.com/article/20160321/NEWS/160329976/will-the-anthem-express-scripts-battle-change-the-pbm-landscape