Medical Benefits Cost and Claims Recovery

Medical Benefit Cost Reduction
Let’s face it, employee benefit costs are escalating dramatically. Most American Businesses are faced with the choice of limiting coverage, increasing participant costs, increasing co-pays and deductibles or all of the above. None of these are good for employee morale and none are decisions that owners or Management want to make, yet we are all faced with the certainty that Medical costs have risen considerably over the last decade, and all forecasts are that they will continue to increase even more over the years to come.

We have the solution, and it does not include limiting coverage, increasing costs or even changing providers. Our team of experts knows the components that go into the premiums you are paying because they themselves used to work as actuaries for the leading benefit providers in the Country. They know the assumptions being used to derive the pricing, they know the built in profit margins (have you taken note of the fact that Insurance companies, just like Big Oil, continue to set record profit levels, month after month?).

Our experts can deconstruct and reverse engineer your historical claims data. With the facts and data that our analytic tools produce, we can go back to your current providers and cut your costs, often dramatically. We will also show you rebate programs that many Companies are unaware of, and these can produce substantial dollars.

Whether you are fully insured, or self insured, we can review your current programs and show you the areas where cost-reduction is possible. As with all of our services, our recommendations are “no-obligation” and our services are offered on a contingency fee basis.

Medical Claims Audit
Healthcare costs account for 16% of the nation’s economy. For most companies, the necessity to outsource most of the claim adjudication processes makes it the least monitored corporate expense. Claims are often overpaid due to fee structure misapplication, duplicates, unimplemented benefits, CPT coding errors and claim payer errors. Due to the complexity of healthcare issues and ever-increasing medical costs today, relying solely on traditional in-house or third party review is simply not cost-efficient. Our solution encompasses a suite of comprehensive examinations including analytical, prospective and retrospective audits. Utilizing unique proprietary electronic edits, database analyses and focused audit procedures delivered by healthcare industry claim experts, we excel at claim cost containment and recovery services. With documented audit results of up to 8% identified overpayments, our unique approach provides direct impact on financial and service quality improvement.

Initially, clients may elect to adopt a specific service based on immediate needs, and evolve to the full scope of the program over time for maximum and sustained benefits. Cash savings and future healthcare savings are generated through two major program components:

Identification and Recovery
Systematic retrospective claims audits scrutinize all aspects of the claims process for error identification and correction. Typically, retrospective audits analyze 2 years of paid claims history and recover on average 2 to 5% of total claims paid. Errors found in retrospective audits often identify system-wide issues that require correction to control future errors. This can lead to cost reduction proactively, in addition to the money recovered on overpaid claims.

Ongoing Proactive Savings
For clients with a need to continue monitoring potential overpayments, we can utilize claims analysis tools to proactively monitor claims data to ensure accuracy on a timelier basis than the 2- year retrospective audit. This can be structured in coordination with Human Resource and Internal Audit personnel to educate them on identifying potential errors.

Profit Advisory Group and our specialist partners pride ourselves on being as non-invasive as possible and generally require only minimal resources to begin. Trained experts examine and review 100% of your past transactions. Our performance-based compensation is contingent on results and calculated exclusively on a share of the savings our services generate. We are committed to being your partner in ensuring your medical claims financial integrity!

Contact us at Info@profitadvisorygroup.com