The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.


Are Your Employees Getting the Benefits You Think You’re Providing?

By Truven Staff
Marie Bowker imageDespite 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.

Marie Bowker
Senior Director, Practice Leadership

"Wellness Checks" for Your Health Plan Administration

By Truven Staff
Marie Bowker imageWe all know how important it is to stay current with preventive screenings and wellness visits to ensure our personal good health. But “wellness checks” for your health plan administration are also critical to the financial well being of your plan.  After all, you want to be confident that your claims administrator is paying claims correctly and in compliance with your contract and benefit plan designs so there are no big surprises down the road.
Yet I’m always surprised when I talk with a benefits manager who has worked for a company for 5 to 10 years, and they can’t recall ever conducting an audit of their claims administrators.  A claims audit is an important wellness check that should be conducted every year, and it should be a priority for every plan sponsor who wants to reduce wasteful spending caused by administrative errors and fraud and abuse.

Most administrative contracts put restrictions on the time period of claims that can be audited and limit how far back they will pursue recoveries for errors.  The longer a plan sponsor waits to conduct an audit, the more dollars they forfeit from a recovery perspective.  More importantly, failing to regularly conduct audits allows continued wasteful leakages from plan funds because errors are not identified and corrected soon enough.

As the old business adage goes, you can’t manage it if you don’t measure it.  So add an annual health plan claims audit to your calendar of wellness checks. I know from my experience that this is the only way you can be confident you’re maximizing the financial performance of your healthcare benefit.

For more information on improving payment accuracy and reducing cost trends, download the Top Seven Money Errors Made by Plan Sponsors Insights Brief.

Marie Bowker
Senior Director of Practice Leadership