The ability to understand and identify risks within your organization’s health plan, as well as the likelihood and overall impact, enables our people to customize an engagement that integrates with your risk management process and risk appetite.

The goal of these engagements is to work in conjunction with your risk management process, instead of as a stand-alone engagement, to eliminate unacceptable risks; reduce unacceptable risks to an “acceptable” level if the risks cannot be eliminated; or transfer unacceptable risks.

Healthcare Claims Audit

healthcare claims audit article

Read our article, How to Plan and Design a Thorough Health Care Claims Audit.

Even the industry’s best claim administrators are estimated to have claim payment error rates that range from 2% to 5% of overall medical claims costs each year. Can you continue to afford to ignore this risk?

A healthcare claims audit is defined as an independent and objective examination and analysis of (a portion or the entirety of) a third party administrator’s claims adjudication process, pursuant to plan guidelines and generally accepted industry standards. This evaluation may take place prior to the implementation of plan benefits (i.e., a pre-implementation audit) or after plan benefit adjudication has begun (i.e., post-implementation or retrospective audit).

Clients routinely engage us to evaluate the administration of:

  • Medical Benefits
  • Mental Health and Substance Abuse Benefits
  • Dental Benefits
  • Vision Benefits
  • Supplemental Sickness/Disability Benefits
  • Flexible Spending Account

Going well beyond the traditional healthcare claims audit, our multidisciplinary auditors utilize a risk-based engagement approach to identify, target, assess and mitigate key risks within the claim cycle for the purpose of safeguarding assets. Our auditors work collaboratively with third party administrator’s to maximize engagement results and recovery opportunities. Engagements may incorporate one or more of the following service offerings:

A 100 percent evaluation of a full claims population designed to identify claim payment errors using our proprietary software and logic. Testing can be performed in the following categories: eligibility, benefit structure, pre-payment edits, other fees and charges, and suspicious and wasteful billing practices.

A random statistical sample approach used to measure and report a third party administrator’s compliance with claim adjudication performance guarantees and industry standards. Results can be extrapolated to the full sample claims population.

A random or judgmental sample approach used to measure and report a third party administrator’s compliance in a targeted population. Only a random statistical sample can be extrapolated to the full sample claims population. A judgmental sample cannot.

A review of a third party administrator’s claims operation procedures and controls for the purpose of identifying and facilitating improvement in quality and efficiency, thereby reducing cost.

Our Dependent Eligibility Verification Evaluations are designed to reduce the plan’s healthcare costs by identifying, and removing, ineligible dependents enrolled in the plan. Contact us today to learn more.

Dependent Eligibility Verification Evaluation

In the age of rising healthcare costs and healthcare reform, the risk of waste and abuse within a health plan is growing. Through performance of dependent eligibility verification evaluations, the industry is finding that, on average, between 3% and 8% of dependents within a plan were ineligible. As a plan sponsor, you have a fiduciary responsibility to ensure the members and dependents of the plan are compliant with its eligibility requirements.

A dependent eligibility verification evaluation is an independent and objective examination of the enrolled dependents in an employer’s health plan to ensure they are eligible to participate based on plan guidelines. This evaluation may take place at any time during the year, but most commonly coincides with open enrollment.

We will work with you to ensure the tone of the engagement fits the culture and sensitivity of your organization. Our consultants are trained to meet the goals of the evaluation by utilizing professional and objective techniques when interacting with the members of your plan. We will also work with you to implement a strategy to effectively communicate the intent of the review to your employees to minimize employee disruption.

We offer two different types of dependent eligibility verification evaluations using our proprietary process and software to meet your needs:

An affidavit evaluation is the least disruptive eligibility verification process we offer. This process is designed for those organizations that want to address the exposure of ineligible dependents, but are not ready for the comprehensive evaluation services.

In an affidavit evaluation, our trained consultants will contact each employee with enrolled dependents in your health plan to obtain certification that each dependent meets the eligibility requirements of the plan. This process is designed to cover 100 percent of the dependent population. Those dependents that the employee voluntarily identifies as failing to meet these requirements are immediately removed from the plan. Additionally, at the conclusion of the engagement, the dependents of those employees who fail to respond to the request are also removed. Dependents may be reinstated once, and if, the proper certification is obtained.

Although this is the least costly and intrusive of the two service offerings, because no documentation is required from the employee to validate dependents, its effectiveness is limited.

A comprehensive evaluation is an independent certification or re-certification of the eligibility status of 100 percent of the enrolled dependents in your health plan. It is the most extensive and exhaustive dependent verification service available.

In a comprehensive evaluation, our trained consultants will contact each employee with enrolled dependents in your health plan to obtain the agreed-upon documentation that is necessary to validate the eligibility of each dependent based on plan guidelines. As the participants provide us with documentation, our consultants will review the support to determine its adequacy and compliance with plan requirements. We will work with participants who provide inadequate or noncompliant support in an attempt to minimize the number of participants whose documentation is incomplete.

This evaluation often involves an amnesty period, during which an employee may remove a dependent from the plan without consequence. Ineligible dependents are generally removed from the plan immediately. The ineligible dependents may be reinstated once, and if, the proper documentation is provided.

The level of detail required for an employee to certify a dependent makes this service more effective than the affidavit evaluation approach and yields the greatest savings to the plan.

Other Services

Our highly trained professionals have deep industry knowledge, meaningful insights and a broad range of capabilities with respect to the proper administration and adjudication of healthcare benefits and claims. Examples of other services we offer that are not detailed above include:

  • Administrative Services Agreement Evaluation and Compliance Services
  • Cash Flow Evaluation
  • Claims Processing and Adjudication Controls Evaluation
  • Contribution Rate Determination and Assessment
  • Litigation Support
  • Proposal Analysis
  • Risk Identification, Assessment, and Monitoring
  • Usual, Customary, and Reasonable Pricing Evaluation

If you need help understanding and identifying the risks associated with your health plan, we can help.
Contact us today and we can work with you to eliminate, reduce or transfer unacceptable risks.