COMPREHENSIVE CLAIMS AUDITS FOR SELF-INSURED EMPLOYERS IT IS WHAT WE DO. IT IS ALL WE DO.
THE MOST TRUSTED HEALTHCARE CLAIMS RECOVERY PARTNER
% 100
DIFFERENCE
HEALTHCARE HORIZONS’
DIFFERENCE EVERY CLAIM. EVERY DOLLAR.
100% Difference. We drill deeper. Recovering dollars is a bottom-line return on investment.
• Typical audits consider only randomly selected claims, missing dollars that may be hiding right next to where you are drilling. • Comprehensive audits drill in every area, recovering your dollars.
Errors happen. People are not perfect. The BIGGEST ERROR is ignoring what is left behind.
• As many as 1 in 10 bills paid by private health insurance contain mistakes. • A random-sample audit will not review every claim, leaving thousands of dollars unrecovered.
We make it right. Finding the source. Correcting the problem. Putting things back as they should be. • Our expertise works for you. Our expert data review process triggers creation of custom queries for ‘best probable error’ selection, identifying more systemic errors and leading to increased future savings.
• We make it simple. We do most of the work, keeping you up-to-date along the way. It is our job to take a closer look, so you don’t have to.
• Low risk. High return. Contingency audits keep your risks low. The return is more recovered dollars for your bottom line.
An opportunity is on your horizon. Accurate information enables HR to add to the bottom line.
• Complete and accurate information puts you in the best position to define what is right for your workforce.
• Until YOU are satisfied. We monitor the recovery efforts of overpaid claims by your thirdparty administrator until you are satisfied.
Why the 100% Difference Audit? 100% DIFFERENCE
REVIEW:
100% of claims paid
TYPICAL INDUSTRY AUDIT
REVIEW: Random sample of claims paid
TYPICAL INDUSTRY AUDIT
FOCUS: Analyzing ALL claims data to find errors
FOCUS: Establishing an acceptable error rate (missed opportunity to find systemic errors
OUTCOME: Recovered dollars returned to you, the client
or large one-off mistakes)
OUTCOME: Likely low audit findings
TYPICAL INDUSTRY AUDIT
COST: Pays for itself through recoveries COST: Borne by the client (typically, fixed-fee arrangement)
IMPACT: Respectful relationship with your TPA to uncover root cause of errors for future cost savings
IMPACT: Payers are often unwilling to correct all claims affected by a random sample audit finding
SMALL CLAIMS: 100% Difference means thousands of claims add up to thousands of dollars
SMALL CLAIMS: Typical audits randomly select a small percentage of claims in each lower-dollar category (possible systemic error patterns overlooked, missing broader savings)
Healthcare Horizons’ 100% Difference means more real dollars to you.
More than
$80
million
recovered for our clients
How it works. Claims audit timeline. 1
2
3
4
5
DATA GATHERING
DATA MINING
TPA PREP
SITE VISIT & REPORTING
RECOVERY
Healthcare Horizons gathers data from client and TPA Audit scope to TPA
Healthcare Horizons analyzes data
Provides claims selections to TPA
FOR
SITE VISIT
TPA reviews sample claims findings in preparation of site visit by Healthcare Horizons
Healthcare Horizons visits TPA and provides reports to Client and TPA of audit findings and recommendations Approve claims for recovery Review remediation steps by TPA
Client decides which claims to recover TPA recovers overpaid claims Healthcare Horizons tracks collections and reports progress to client
We look under every stone. WE SEARCH TO FIND ERRORS AND/OR OVERPAYMENTS, TAKING INTO ACCOUNT: ELIGIBILITY
ABUSIVE BILLING/FRAUD
MEDICAL CODING ACCURACY
DUPLICATE BILLING
BENEFIT MAXIMUMS
CONTRACTED RATES
EXCLUDED SERVICES
COORDINATION OF BENEFITS
INPATIENT RE-ADMISSIONS
MODIFIER PRICING
PATIENT RESPONSIBILITY
AND MORE …
Case Studies Healthcare Horizons identified an issue regarding
Healthcare Horizons identified an instance in
the administration of a benefit maximum. The
which a surgical implant was billed incorrectly
overpayments were due to a combination of
at $777,000 vs. $77,000. As the reimbursement
inconsistent billing by the facilities and manual
was based on a percentage of the charges, the
processing by the claims administrator. After review by Healthcare Horizons, the client
recovered more than $1 million in overpayments, and a root-cause correction was implemented to prevent future overpayments.
SKILLED NURSING BENEFIT MAXIMUM
billed charge amount had a significant effect on the final payment, resulting in an overpayment of $300,000.
INCORRECT/HUMAN ERROR BILLING
Finalizing the process. RECOVERED DOLLARS ARE DEPOSITED INTO YOUR ACCOUNT. Healthcare Horizons is paid only after the recovered dollars are deposited into your account.
WE DELIVER A REPORT OF RECOMMENDATIONS TO AVOID FUTURE ERRORS. Once our audit is complete, we make plan benefit recommendations that help produce future savings.
The 100% Difference Report HOW YOUR HEALTHCARE HORIZONS AUDIT REPORT WORKS FOR YOU.
• We summarize the total dollars identified by issue. • We provide details on each selected sample claim error and the dollar impact.
• We make recommendations regarding plan design, root-cause correction, and benefit changes.
People first. YOU ARE IN CHARGE
CLEAR COMMUNICATION
You determine which claims to recover.
We keep you informed and up-to-date on the process.
You decide how hands-on you want to be.
We take special care to alert you so recovery decisions are made with an understanding of member impact.
TPA RELATIONSHIPS RESPECTED Healthcare Horizons works with your TPA to identify errors, monitor collections, and help negotiate direct credits or settlements.
Benefits HIGH YIELD FOR LITTLE TIME
STREAMLINED PROCESS
Minimal time is required by the client to set up the audit, increasing ROI.
We work behind the scenes so you can focus on your business operations and productivity.
SATISFIES FIDUCIARY RESPONSIBILITY
Performing an annual healthcare claims audit improves your bottom line and avoids the two-year ‘no recovery’ trap.
Our standards are not standard. DATA INTEGRITY AND SECURITY ARE TOP PRIORITIES AT HEALTHCARE HORIZONS. • A HIPAA-compliant data center with multi-level authentication, including secure server token encryption.
• Full drive encrypted laptops with programmed time-outs.
• Secure document and media (CD/DVD) shredding by reputable HIPAA-compliant supplier providing certification of destruction.
• Healthcare Horizons’ physical environment is secured using 24/7 badge-entry systems, desk and key-entry locks, and alarm systems.
• Use secure, encrypted email with secure ftp or http protocols.
• Employees undergo extensive background checks and receive ongoing HIPAA training.
If hindsight is 20/20, we give you perfect vision. • Healthcare Horizons focuses exclusively on self-insured employers. It is what we do. It is all we do.
• Our 100% Difference guarantees you more. More ROI. More future savings. • People first! Our emphasis is on YOU and providing unmatched, superior personal service.
• HIPAA-compliant. Safeguarding your employees’ protected health information and data is top priority.
• Hands-on involvement from Healthcare Horizons’ leadership for every audit. • High sensitivity to TPA relationships.
Trusted Partner. Uncompromising Accuracy. Superior Personal Service.
RECOVERED CLAIMS
AUDITED CLAIMS
We have recovered millions of dollars for some of the world’s largest employers, ranging from retail to local government.
We have audited claims by all national and most regional third-party administrators.
Getting the most from your RFP process. WHAT YOU NEED TO KNOW KNOW YOUR AUDIT RIGHTS
• Contingency or fixed-fee pricing? • Comprehensive vs. random sample approach?
• How much of your time will be required
• How many claims can be reviewed on-site?
• What is the expected timeline of the project?
• Audit period allowed?
• Who decides which claims get recovered?
KNOW YOUR AUDITOR
• Who monitors collections?
• Does the claims audit firm identify systemic
• Does the claims audit firm negotiate direct credits
errors and make root-cause recommendations to keep costs down?
• What is the level of expertise and experience of the claims audit firm?
• What are the HIPAA practices and compliance of the claims auditing firm?
throughout the process?
or settlements from the TPA for you?
• What categories do you review/where do you look to find errors (such as medical coding, exclusions, eligibility)?
• How do you put the final report to use for the client?
Getting the most from your RFP process. WHAT THE CLAIMS AUDIT FIRM NEEDS TO KNOW
• What is the timetable of the RFP process and project completion expectation?
• What timeframe will you audit (to avoid the two-year 'no recovery' trap)? • How many plans do you have? • How many subscribers do you have? • What is the annual medical expense?
• Who is your TPA? • Are there any known issues, problems, or concerns?
THE MOST TRUSTED HEALTHCARE CLAIMS RECOVERY PARTNER
When Close Enough … Isn’t WWW.HEALTHCAREHORIZONS.COM
(800) 646-9987