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Healthcare costs account for 16% of the nation’s economy. For most companies, the necessity to outsource most of the claim adjudication processes makes it the least monitored corporate expense. Claims are often overpaid due to fee structure misapplication, duplicates, unimplemented benefits, CPT coding errors and claim payer errors. Due to the complexity of healthcare issues and ever-increasing medical costs today, relying solely on traditional in-house or third-party review is simply not cost-efficient.

Our solution encompasses a suite of comprehensive examinations including analytical, prospective and retrospective audits. Utilizing unique proprietary electronic edits, database analyses and focused audit procedures delivered by healthcare industry claim experts, we stand as the leading one-source provider of claim cost containment and recovery services. With documented audit results of up to 8% identified overpayments, our unique approach provides direct impact on financial and service quality improvement.

Initially, clients may elect to adopt a specific service based on immediate needs, and evolve to the full scope of the program over time for maximum and sustained benefits. Cash savings and future healthcare savings are generated through three major program components:

Identification and Recovery

Systematic retrospective claims audits scrutinize all aspects of the claims process for error identification and correction. Typically, retrospective audits analyze 2 years of paid claims history and recover on average 2 to 3% of the total claims paid. Errors found in retrospective audits often identify system-wide issues that require correction to control future errors. This can lead to cost reduction prospectively in addition to the money recovered on overpaid claims.

 

Operations Review and Recommendations

An independent and objective view of the claims processing practices and procedures is conducted during the claims recovery process to evaluate administrative and claims policy compliance, assess performance standards and identify processing issues. Our analysis can assist Benefit Administrators in measuring program performance and monitoring ongoing effectiveness of cost-containment initiatives and benefit changes.

Ongoing Prospective Savings

For clients with a need to continue monitoring potential overpayments, we can utilize our claims analysis tools to proactively monitor claims data to ensure accuracy on a more timely basis than the 2-year retrospective audit. This can be structured in coordination with Human Resource and Internal Audit personnel to educate them on identifying potential errors.

The Healthcare claims review, in light of the current changes taking place today, might be a smart move to insure you are not wasting any of your hard-earned profits!

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