Self-Funded Health Claim Audits

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CBIZ will perform an audit of health care claims paid by employers' Third Party Administrators to identify overpayments and payments for non-covered services. The audit will focus on areas like surgical reimbursements, medical inconsistencies, duplicate payments, and compliance with deductibles and maximums. CBIZ will also review administrative agreements and provide recommendations to improve cost effectiveness and oversight. Audits typically identify payments exceeding costs, providing savings for self-funded employers.

Healthcare

Self-Funded
Health Claim Audits
Knowing that health insurers sometimes make mistakes in processing and paying claims, experts advise
employers to audit their health plans every two or three years.
Insurers aren’t perfect and won’t promise perfection, but it’s important to hold them accountable for
factors over which they have direct influence.
In an effort to meet the objectives of employers maintaining self-funded medical plans, CBIZ will perform
an analytical review and exception item validation study of health care claims paid by the Third Party
Administrator (TPA).
The reviews are specifically designed to identify payments beyond specific benefit reimbursement levels
and for non-covered services, as well as other specific exception conditions.
CBIZ will focus on certain risk areas such as:
Some of the reasons employers may want to perform theses audits are:
Assistant surgical reimbursement issues
Multiple/bilateral surgical reimbursement issues
Medical consistency exceptions
Additional coverage exclusions
Deductible/co-payment and maximum
application
Potential excess hospital/medical surgical
charges
Potential fraud and abuse
Payments for ineligible patients
Duplicate and erroneous claims payments
Erroneous payments/benefit levels
Other third-party liability
Provider payment review (hospital and physician
discount contracts)
Cash flow balancing
CBIZ will also perform a comprehensive review of the employer’s Administrative Services Agreement to
ensure effective administration and enhancement of current provisions. CBIZ will prepare and deliver
recommendations regarding effective administration, cost, performance standards, etc.
Due diligence for public companies and ERISA purposes.
Potential payback is in excess of two times the cost.
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For more information, please contact:
Phyllis Hoff: 314-692-5887 / phoff@cbiz.com Ryan Kuryla: 314-995-5542 / rkuryla@cbiz.com
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Should an Employer Be Self-Funded? That is quite a question. In the past we cautioned that claims savings was not guaranteed by self-funding. And with a small difference in fixed fees vs. fully insured retention, there was not much incentive for smaller employers to take the risk, given that they were more susceptible to wide fluctuations in claims cost. Review our research and analysis on self-funding to help determine if the program is the right fit for your business. Contact McGohan-Brabender to discuss self-funding in detail. https://www.mcgohanbrabender.com/

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Self-Funded Health Claim Audits

1. Self-Funded Health Claim Audits Knowing that health insurers sometimes make mistakes in processing and paying claims, experts advise employers to audit their health plans every two or three years. Insurers aren’t perfect and won’t promise perfection, but it’s important to hold them accountable for factors over which they have direct influence. In an effort to meet the objectives of employers maintaining self-funded medical plans, CBIZ will perform an analytical review and exception item validation study of health care claims paid by the Third Party Administrator (TPA). The reviews are specifically designed to identify payments beyond specific benefit reimbursement levels and for non-covered services, as well as other specific exception conditions. CBIZ will focus on certain risk areas such as: Some of the reasons employers may want to perform theses audits are: Assistant surgical reimbursement issues Multiple/bilateral surgical reimbursement issues Medical consistency exceptions Additional coverage exclusions Deductible/co-payment and maximum application Potential excess hospital/medical surgical charges Potential fraud and abuse Payments for ineligible patients Duplicate and erroneous claims payments Erroneous payments/benefit levels Other third-party liability Provider payment review (hospital and physician discount contracts) Cash flow balancing CBIZ will also perform a comprehensive review of the employer’s Administrative Services Agreement to ensure effective administration and enhancement of current provisions. CBIZ will prepare and deliver recommendations regarding effective administration, cost, performance standards, etc. Due diligence for public companies and ERISA purposes. Potential payback is in excess of two times the cost. . . For more information, please contact: Phyllis Hoff: 314-692-5887 / phoff@cbiz.com Ryan Kuryla: 314-995-5542 / rkuryla@cbiz.com . . . . . . . . . . . . . .

Self-Funded Health Claim Audits

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