Podcast

Feel the Love with Medical Claims Audits

In today’s competitive job market, attracting and retaining top talent is crucial for any organization. Happy and healthy employees are more productive, engaged and loyal. That’s why prioritizing employee well-being and managing the costs of a company’s self-funded health insurance plan are ongoing necessities. Show them the love!

Setting up a self-funded health insurance plan is a financially beneficial approach for many larger organizations. By paying for medical claims directly, company leaders have more say in what coverage is offered and eliminate the middleman in payments. However, this also includes the responsibility for uncovering any overpayments and working to have those dollars returned to the company.

Fortunately, human resource leaders who recognize they don’t have the expertise – or time – to review every medical claim paid by their health plan have a strong option available to them: Comprehensive medical claims audits. These audits look at every claim paid by a plan and identify anomalies or egregious payments. These suspicious payments are then analyzed by a claims expert. Once the errors have been flagged, the client will determine which overpayments are pursued for recovery of dollars.

Who does this process benefit? Everyone!

Clients Show Love to Their Employees When They Audit

Company employees obviously are negatively impacted by overpaid health claims because they are paying more. This may be because of an incorrectly charged co-pay, a procedure being mislabeled as out-of-network rather than in-network or reaching plan maximums sooner than they should. However, employees also lose out on other potential workplace benefits because the overpaid dollars could have been used for other programs, such as wellness incentives or additional PTO. Just think what a return of $1000, $10,000 or $100,000 could fund!

Clients Show Love to Their Stakeholders When They Find Errors

Employees are not the only ones impacted when medical errors are left uncorrected. Anyone invested in the company’s success loses when the bottom line isn’t as robust as it should be. Whether a shareholder in a publicly traded company, a vendor that provides a service or a customer, when funds must be reallocated due to overspending on healthcare, the impact is felt.

We Love Our Clients

At Healthcare Horizons, we are passionate about what we do. We want to help protect our clients’ investment in health coverage. Our “every claim” approach means nothing is left to random chance. We want to ensure that overpayments are not only recovered but also that any ongoing errors causing the faulty charge are addressed and fixed. Finally, we believe that our clients are more than just a faceless entity. We are proud of the relationships we have developed over the years with public, private and government organizations.

No one wants waste in the healthcare system. What we do benefits individuals, corporations and even healthcare practitioners. When costs are accurate and transparent, there is a stronger level of trust in the healthcare system, more people can afford care and dollars can be invested correctly in new technologies or treatments. And that’s something we all can love.

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.

new year goal through a magnifying glass

New Year Goal: Fiscally Sound Self-Funded Health Plan

Is a key company New Year goal to have more fiscal control of your self-funded insurance plan? If so, there is one important message you need to hear and one important step to take to help protect your plan.

Not Everyone is Looking Out for You

If you take away nothing else from this information, heed this message: the only person concerned with maximizing your investment is you.

When companies self-funds their medical plan, they are responsible for every aspect of the plan – from full payment to legal requirements. Other plans have varying levels of partnership between a fully-funded plan and investment by the company. As corporations grow it often makes more sense to eliminate the go-between in funding and payment, not only to save on costs but also for more flexibility on the plan offerings.

While third-party administrators (TPA) can and do help manage self-funded plans, the TPA has no financial incentive to control costs. Their money is not on the line. When your financial balance sheet is the one directly impacted, you are much more likely to review payments and processes more carefully.

Audits are Insurance for Your Plan

So, what one step best ensures that you aren’t overpaying medical claims? Annual comprehensive claims audits.

Let’s be honest, human resource executives and benefits managers are busy. Few have the time to review the vast volume of medical claims submitted through employer-funded insurance policies. Even if they did, they may not have the specialized knowledge to properly identify the many types of possible errors. The good news is that they don’t have to!

A true comprehensive audit process is not a software solution. If it were, the same logic would be built into claims systems to stop overpayments from happening in the first place. We audit all aspects of the adjudication process from receipt to payment of the claim. Our comprehensive approach has offered our audit team a reference point for every kind of error possible. This has allowed us to recover millions of dollars in overpayments for our clients.

When our team is on site (physically or virtually), we work individually through each claim selected to resolve the specific questions that arose in the data-mining phase of the project. When the site visit is complete, we look back at the entire dataset to find all additional occurrences of systemic or repeatable errors. Healthcare Horizons customizes the most comprehensive audit process possible for every one of our clients to ensure positive outcomes. Once our audits are complete, we will make plan benefit recommendations for improvement and root cause correction.

The audit is designed to be a positive process between Healthcare Horizons, the client, and their administrator. We take pride in the excellent working relationships we have developed with third-party administrators and our clients. Healthcare Horizons may occasionally request assistance from the client when a clear definition of plan intent is required. Additionally, we can provide guidance to help our clients negotiate direct credits and monitor the recovery of claims payments until the client is satisfied. Whatever you choose, the goal is to return the most money to your bottom line. After all, it’s your company’s money and it should be available to use to provide more benefits to your employees.

Achieve Your New Year Goal with a Sound Plan

Fortunately, while the idea of a comprehensive audit may sound daunting, Healthcare Horizons is committed to identifying errors that will provide a positive return on investment for our clients, while comprehensively assessing the performance of claims payers.

So, this year, keep your resolution to make your self-funded employee health benefits plan as financially sound as possible. Schedule your free assessment to get started returning overpaid claims dollars back to your company’s bottom line, where they belong!

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.

Perfect Holiday Gift: A 2016 Audit

All of us at Healthcare Horizons hope 2016 has been a memorable year for you, your colleagues, and your loved ones. Thank you for giving us the opportunity to do what we do best. Our specialty, of course, is helping companies that self-fund all or part of their healthcare programs. In recent months, some of our money-saving tips have drawn attention in leading industry publications.

Here is our BenefitsPro blog about ways to avoid huge charges when employees reach out-of-pocket maximums yet continue to use non-par providers.

And here is our article in Employee Benefit News that discusses how TPA random sample audits often fail to catch sizeable medical overcharges.

We hope you have a joyous holiday season and we look forward to working with you in the years to come. The best gift you can give your company is a thorough 2016 healthcare spending audit that can produce significant savings. It’s the perfect way to ring in the New Year!