Podcast

How to Grow Your 2025 Healthcare Budget

In today’s competitive healthcare landscape, managing costs effectively is crucial for the sustainability of healthcare benefits for an organization and its employees. The budget process, encompassing everything from forecasting to allocation, is a cornerstone of financial health. For companies self-funding their health insurance plan, this process is even more important. While the budget process might seem straightforward on the surface, it’s often fraught with complexities that can impact both the financial health of the organization and the quality of benefits offered to employees. It’s time to grow your budget!

The Challenges of Self-Funded Healthcare Budgets

As you crunch numbers and prepare your 2025 budget, healthcare spending can be one of the more difficult line items to predict for numerous reasons:

  • Rapidly Evolving Healthcare Costs: Healthcare costs continue to rise at a significant rate, making it difficult to accurately predict future expenses.
  • Unpredictability of Needs: While past data is helpful, illness and injury cannot always be planned for and may be more serious than expected.
  • Regulatory Changes: The healthcare industry is subject to frequent regulatory changes, which can impact both costs and compliance requirements.
  • Emerging Healthcare Trends: New technologies, treatments, and care delivery models can introduce both opportunities and risks to the budget.
  • Data Complexity: Analyzing and interpreting complex healthcare data can be time-consuming and challenging for organizations without specialized expertise.

Enlist Help to Find Lost Dollars and Grow Your Budget

While benefits managers may have a strong understanding of their organization’s needs and the history of their plan, they may lack the specialized knowledge and tools required to navigate the complexities of self-funded healthcare budgets for the reasons mentioned. Partnering with a professional benefits consultant can provide the expertise and support needed to ensure the sustainability of healthcare benefits and protect – or even grow – the healthcare plan budget. One tool to achieve this goal is a healthcare claims audit.

Healthcare claims audits ensure accuracy, identify potential fraud or abuse and recover overpayments tied to employer healthcare plans. At Healthcare Horizons, we use a comprehensive audit method to track every claim and recover the most dollars possible. Our experienced auditors are adept at recognizing the red flags in a healthcare data set that may indicate an overcharge, systemic error (one that keeps repeating and snowballs into huge losses) or fraud. Once a claim is flagged as suspicious, we begin the process of working with the third-party administrator to correct the mistake. Once all parties agree the issue has been properly identified, the overpaid dollars are returned to the plan’s bottom line.

Healthcare claims errors typically range from 1 to 3 percent of total claims and can cost employers hundreds of thousands of dollars annually. That is a substantial piece of a budget.

Don’t Miss Out on Funds in Your Next Budget

Healthcare claims audits are an excellent tool to protect your self-funded healthcare plan. However, this strategy is most effective when combined with a solid service agreement with your third-party administrator. We will also review your current service agreement to ensure that it includes full audit rights. Limited (such as random sample audits) audit rights mean you can’t control what is analyzed – or how much money you may be entitled to have returned.

By leveraging the insights and tools offered by professionals, organizations can make informed decisions, optimize their budgets and protect their financial health in the face of an ever-changing healthcare landscape.

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

Heart Care Funding is Not Just for February

woman holding healthy heart on shirt after preventative care exerciseFebruary 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.

  1. 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.

  1. 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.
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.

Every Claims Data Set Has Errors – Part 2

Last month, we examined a few of the top categories of claims payment errors. Because every healthcare claims data set has errors — people make mistakes — it is important for self-insured employers to perform an independent, fully comprehensive audit annually to identify errors, correct  systemic issues for future savings and recover claims that were paid erroneously. 

Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly. It is an important fiduciary responsibility of the self-insured employer. 

In this blog, we take a closer look at three more common data set errors.

Top categories of claims payment errors

  • Duplicate payments
  • Eligibility
  • Coordination of benefits
  • Medical edits
  • Inpatient readmissions
  • Multiple procedure reductions 
  • Out of network reimbursement
  • Benefit maximums
  • Benefit exclusions 

Assistant Surgeon

Healthcare Horizons tests two common areas of overpayments for assistant surgeons: pricing and coding. Assistant surgeons usually receive a percentage of the normal fee schedule rate for the codes used with assistant modifiers, and we identify any claims paid that are greater than this rate. Additionally, we identify claims as possible overpayments for procedure codes that Medicare does not allow payment for an assistant surgeon. 

Hospital Mistakes

Many payers across the country have adopted policies to investigate and subsequently deny payment for hospital mistakes and avoidable conditions, such as objects left in a patient during surgery, fractures incurred in the hospital, blood incompatibility and certain types of infections. We put expert eyes on claims data for these types of hospital errors and expect recovery opportunities as more administrators adopt such policies.

Medical Edits

We apply medical edits to the claims data to identify mutually exclusive procedures and cases of procedure unbundling. Mutually exclusive edits identify procedure combinations that cannot be reasonably performed on the same patient on the same day. Unbundling occurs when a provider bills multiple component codes versus a single comprehensive code, often resulting in higher reimbursement. Payers have discretion over which medical edits to apply as there is not a commonly accepted group of these throughout the industry, so we are generally looking for a reasonable application of a set of edits and questions selected claims that seem to be clear errors.

While many self-insured employers will say “Our TPA has us covered,” and most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. Our expertise and ability to dig deeper into claims data sets allows us to deliver a better return on investment for our clients. 

The Difference is in Knowing.

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.

Every Healthcare Claims Data Set Has Errors

In this two-part series, we will examine a few of the top categories of claims payment errors. Missing these common errors means that self-insured employers are leaving possibly hundreds of thousands of dollars on the table every year.Rather than asking your employees to contribute more in terms of higher premiums or reducing their benefits, self-insured employers should ensure that their TPA is processing and paying healthcare claims correctly.

It’s our job at Healthcare Horizons to take a closer look and return those dollars to the bottom line.

Top categories of claims payment errors

  • Duplicate payments
  • Eligibility
  • Coordination of benefits
  • Medical edits
  • Inpatient readmissions
  • Multiple procedure reductions
  • Out of network reimbursement
  • Benefit maximums
  • Benefit exclusions

Duplicate Payments

While most clients would expect duplicate claims to be rare, they are actually quite common in healthcare claims payments and usually result in recoveries on every project conducted by Healthcare Horizons. A recent audit turned up nearly $50,000 paid in error in just 10 duplicate paid claims.

Eligibility

It is important to validate coverage on the service date.  Employer groups often submit retroactive terminations to the administrator, resulting in an opportunity for overpayments unless the administrator has a process in place to identify and recover these claims. In addition to claims paid after the termination date, Healthcare Horizons identifies claims paid during a gap in coverage and claims paid without an eligibility record on file.

Multiple Procedure Reductions

When multiple services are performed in the same session, secondary procedures are priced at a reduced percentage (usually 50 percent) of the normal contract rate. This automatic reduction accounts for savings gained by only having to prepare a patient once for multiple procedures. We flag claims that may have missed this standard discount by reviewing the secondary procedure allowance.

We often hear the words, “Our TPA has us covered,” and while most TPAs do a good job of processing claims, it is our business to conduct thorough, 100% Difference annual audits that return money to our clients. People make mistakes. Healthcare Horizons is committed to finding every claim and every possible dollar for our clients.

The Difference is in Knowing.

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.

A $40 Fee to Hold Your Baby?

Here is a link to a story about how one hospital charged a woman nearly $40 to hold her baby after it was delivered.

https://www.vox.com/2016/10/4/13160624/medical-bills-birth-delivery

And here is a link to Steven Brill’s article, “Bitter Pill: Why Medical Bills are Killing Us” from TIME magazine.  This article, “The $21,000 Heartburn Bill,” discusses other outrageous charges.

http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf

These types of absurd charges are driving healthcare costs higher, especially for self-insured employers who are not auditing every claim.

Contact Healthcare Horizons today and let us help you achieve greater transparency and savings.