Health Claims Consultants Inc. has performed health claims audits for self-insured employer groups throughout the United States for over 20 years. Mrs. Harper has directed audits at major and midsize claims administrators that have resulted in overpayments up to five million dollars. Mrs. Harper’s dedication and commitment to her clients in identifying and recovering lost health plan dollars are the basis for her success in health claims auditing. The HCCI audit will verify that the claims administrator’s systems and processes are maximizing the claims paying performance and measure how effectively the health plan is being administered.

A claims audit is recommended yearly to protect the Health Plan financial assets and to comply with ERISA standards as it relates to fiduciary responsibility.  The claims audit is an important tool for identifying various types of errors that may be ongoing such as dependent ineligibles, network discounts, coordination of benefits, subrogation claims, plan language compliance, payment calculations, and duplicate payments.  All errors can be costly to a Plan and continue into the future without intervention.     

The average error rate identified in our book of business will range from one to five percent.  The majority of errors are found in the areas of coordination of benefits and the application of network discounts. Claims error rates are impacted by many factors to include the number of provider service areas for employees and dependents, the number of networks accessed by the claims administrator, the complexity of the plan design, and the claims administrator’s performance in claims processing. While the error rate is an important measure of your claims administrator’s performance, a claims audit will also identify errors and system processes that require immediate corrective action.

HCCI’s audit program also identifies all out of sample errors. The important aspect that sets HCCI apart from other auditing companies is that HCCI does not simply perform a random selection of claims and review each of those claims as a single claim without further consideration and comparison to the total population of claims.  HCCI will review all claims that edit as a potential error claim along with all of the related claims either by member, provider, type of service, payment, and any other areas of claims processing.