Podcast

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 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.