Despite the Patient Protection and Affordable Care Act (PPACA) mandate of 100%, pre-deductible coverage for many preventive services, your health plan or Pharmacy Benefit Manager (PBM) may be interpreting or implementing the plan differently. Or, you may think your plan is not paying for services like cosmetic procedures or non-emergency use of emergency departments; but it depends on your health plan’s system setup.
Either way, if your employees aren’t getting the benefits they were promised at enrollment, it can cause major problems for you.
Luckily, there is a solution — a comprehensive audit of 100% of your claims.
From our experience at Truven Health Analytics™, a comprehensive claims audit typically reveals that up to 8% of claims are paid incorrectly. These incorrect payments often point to breakdowns in plan implementation, but they can also crop up if there are other issues like:
- coding errors
- lack of quality control
- administrator system setup issues
- even, fraud and abuse
Truthfully, if you have any question about how your carrier is administering your plan, a comprehensive audit of 100% of claims is in order. How else will you know how your plan is being administered?
Putting your health claims under the microscope and really analyzing them is the only way you can be sure you are maximizing the financial performance of your healthcare benefit and providing all of the employee benefits you contracted to provide. Plus, ensuring your claims are paid accurately — and in compliance with your plan design — could save you millions of dollars.
Plan sponsors can read our latest insights brief, Three Reasons Your Employees Aren’t Getting the Benefits You Think You’re Providing
, to get details about what to look for and how we can help.
Senior Director, Practice Leadership