Errors in claims for healthcare insurance such as double payment or overpayment, and the determination of eligibility and out-of-network benefits are very common. But these mistakes can be easily pinpointed and prevented by companies if they partner with Healthcare Horizons in reviewing the distribution of their medical insurance plans for employees.

A case in point is a large manufacturing company in the US with some 2,500 employees distributed in many branches across the country. For a two-year period, the company racked up a total of $21 million in medical expenses for its employees. The company felt that there was something wrong in the processing of claims that made it pay more than it should.

And so the company hired Healthcare Horizons to conduct an audit-review of the entire process of its healthcare insurance program for employees. In no time, the experienced Healthcare Horizons professionals traced the biggest problem: the inability of the payer engaged by the company to accurately connect the insured members to the contracts associated their specific networks. The confusion in contract compliant was caused by the fact that the covered employees are located in different areas with different payers.

Apart from making payments error-free, Healthcare Horizons also identified the problems of repeated payments, out-of-network benefits and eligibility. When Healthcare Horizons completed the project, it recovered a total of $557,000 for the company and identified about $1 million as overpaid. Non-compliance with contracts also yielded some $200,000 in collected overpayments.

Healthcare Horizons professionals have worked for, or with, many of the major healthcare insurers in the country. Its vast experience with industry payers allows it to conduct self-insured employer reviews much more efficiently and effectively than its competitors. One of the reasons is Healthcare Horizons reviews the entire dataset of claims instead of just a sampling. Thus, it can target specific areas of concern that should be reviewed with the payers and allows it as well to identify the root causes of claims errors so that clients can avoid future overpayment on medical claims

The operations and technology expertise of Healthcare Horizons is boosted by a staff of comprehensive healthcare skills appropriate for specific projects. For example, HH has professionals with experience and credentials in clinical coding, nursing and healthcare finance. The breadth of our professional expertise allows us to identify more complex issues in claims payment as well as devise operational solutions to prevent future occurrences.

In addition to providing claims audit services, Healthcare Horizons also provides other services to assist large self-funded employers manage their healthcare costs. This range of services includes health benefits analysis, pharmacy program review, eligibility reconciliation and process improvement, RFP and contracting services, fee schedule analysis, utilization and network analysis, reinsurance analysis, and cost containment strategies.

Healthcare Horizons offers detailed healthcare claims audits to self-insured employers across the nation that focuses on identifying and recovering overpaid claims that can be returned to the employer’s account. It stands by its pledge that if it does not find the errors in medical claims, it will not ask for payment for its services.

View all John Graham's articles

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About the Author:
John Graham with Healthcare Horizons offers detailed healthcare claims audits to self-insured employers across the nation, with a focus on identifying and recovering overpaid claims that can be returned to the employer's account.

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