Providing Value-Add to Clients
Claim audit service is an extra benefit for brokers to present to clients. Audit services can save clients big money over time. There are 4 significant advantages to brokers who include a claim audit service in their proposed recommendations.
- Healthcare is the largest expense for self-insured employers. They should feel confident that their money is being spent correctly. A broker is held to a high standard by clients to provide the best cost-saving options for their employee plan. Audits ensure that the TPA is held to the same standard.
- When audits save clients money, they are more likely to be repeat customers. Potential new clients will then want to know what methods are being used to contain costs and keep premiums in check.
- Audits can identify systemic problems with claim processing. If problems are uncovered and not corrected, the broker has the opportunity to suggest different services and vendors.
- Analyzing audit findings can reveal trends that allow improvement to RFP questionnaires. Thoughtful RFPs then allow the broker to make the best recommendations for healthcare plans.
Healthcare Horizons’ claim audits are guaranteed to impact at least one, and probably all four, of the benefits listed above. We analyze every claim, not just a small sample of claims, and work with clients to make recommendations for cost-savings opportunities they may be missing in their plan set-up. We not only identify overpaid claims that can be recovered but also discover potential systemic problems that lead to overpayment trends. Recommending claim audit options to your client is a win-win for you and them.
Limiting Audits
August is an important month for TPA negotiations. As brokers move forward to find the best third-party administrator for their self-insured clients, they must be aware of language in the services agreements that may limit the client’s rights to audit claims and recover overpayments.
A hurdle in many new administrative service agreements is a restriction limiting the ability of self-insured clients to have an audit of all claims in their data set.
Why is it important for audits to be freely accessible by self-fund clients?
- While TPAs will commit to some form of internal auditing, they restrict external auditors from conducting comprehensive auditing. This is a conflict of interest. Outside auditors are unbiased and can be used whenever a client feels it’s necessary.
- Few TPAs will conduct internal audits as a part of the contract. Usually, there is an additional cost to perform the audit. Depending on payment structure, outside auditors can perform contingency-based audits where the self-insured client only pays fees after an overpaid claim is recovered.
- Audits conducted on a yearly basis avoid the possibility of claims being unrecoverable. A common eighteen-month to two-year limitation on claim recovery is written in many TPA agreements.
Healthcare Horizons offers a free review of administrative service agreements to ensure that a client’s rights to audits are protected.
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