HomeMedical Claims Audit

Medical Claims Audit

Why Conduct A Health Care Benefits Audit?

The cost of health care benefits is among the largest expense items for most employers. Along with comprehensive healthcare reform, self-insured employers are facing additional pressures to ease the financial strain through conducting audits of their benefits plans. Industry experts in Human Resources along with Internal Audit executives commonly recommend that all sponsors of health care benefit plans periodically conduct an independent audit of their third-party claims administrators.  Many employers have never conducted an audit, yet they provide draft authority on their bank account for the third-party administrator to issue funds to pay the organization’s health care claims.  Increased scrutiny by the Department of Labor relative to proper discharge and monitoring of fiduciary duties by employers and/or sponsors of group health plans may be reason enough to conduct an audit. Plan sponsors put a lot of effort into designing health care benefits for their employees and want to be assured that these benefits are being provided at the right cost.

Below is a listing of popular comprehensive benefits auditing solutions to both self-insured and fully-insured organizations.

  • Medical Claims Audit
  • Prescription Drug Claims Audit
  • Dental Claims Audit
  • Vision Claims Audit
  • Pre-Implementation Claims Audit
  • Other Benefit-Related Audit Solutions
Electronic claims payment systems minimize errors, but the complete claims payment process relies on human judgment. Multiple combinations of factors exist that attribute to claims payment issues such as:

  • Weak investigative efforts
  • Volume pressures
  • Poor claims payment systems or outdated software
  • Internal policies prevail over plan language
  • Human misinterpretation during plan setup
Audit IQ is a Health care claims auditing software designed to efficiently and effectively identify errant payments. Users include: Insurance Carriers, Third Party Administrators, Self-paying Employers, Employers, and Employee Benefit Consultants/Brokers..

Engine – FiLTER iQ is an intelligent and highly selective software analytical engine that can interpret and process benefit design logic. FiLTER iQ is the foundation for AUDiT iQ™’s modules: Medical, Dependent Eligibility, Rx and Dental.

Medical Module: The Medical module comes complete for auditing all aspects of a medical health plan and its associated claims data. A comprehensive set of medical codes are included with the software and are fully integrated into the auditing process. These code sets include: AMA CPT®, AMA HCPCS, AMA ICD-9, and CMS Revenue codes. The Medical module is based on over 80 categories that have been pre-tuned and configured out-of-the-box to use the most appropriate medical codes available. In addition, each category can be configured to capture benefit design metrics related to deductibles, co-insurance, in-network / out-of-network payment levels, dependents, maximums based on occurrences or incidents, and others. Some examples of audit categories include:

  • Duplicates
  • Medical Necessity
  • Potential Other Party Liability
  • Excluded Services (acupuncture, cosmetic procedures, . . .)
  • Limited Services (chiropractic, physical therapy, . . .)
RX Module: The Rx module is tailored for pharmaceutical claims. Categories have been created to effectively audit many aspects of any pharmaceutical benefit plan including co-pays, exclusions, limitations, AWP and MAC pricing discounts, as well as other criteria. It utilizes both historical and current databases published by First Data Bank to define the Rx categories and assist with the analysis of the claims data.
Dental Module: The Dental module comes pre-configured with categories that effectively audit dental claims. Using the American Dental Association’s Current Dental Terminology (CDT) code set, AUDiT iQ™ can intelligently assess benefit design metrics related to co-insurance, exclusions, deductibles, maximum benefits, and others.
Dependent Eligibility Module: The Dependent Eligibility module is designed to accept various plan eligibility criteria and use those factors, along with the eligibility data, to build the communications / mailings, track each employee response, and report those responses in a real-time tabular or graphical manner.

 

 

Animated Social Media Icons by Acurax Wordpress Development Company
Visit Us On TwitterVisit Us On FacebookVisit Us On Linkedin