“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.
[1] https://www.modernhealthcare.com/finance/identifying-addressing-common-medical-billing-errors-pre-post-payment
