Ensuring the accuracy of paid health claims and returning lost dollars to the Health Plan.
Audit Scope
HCCI works with the client to determine the audit scope based on the company’s audit requirements and the Administrative Services Agreement with the claims administrator. The most common audit scope is the most recently processed claims in 18-24 months.
Approach
HCCI will perform an audit for the client that meets its specific audit goals while maintaining compliance with the claims administrator’s audit requirements. Our normal approach is the following steps:
Assists the client in requesting the processed claims data from the claims administrator for the approved audit scope. The data file will include all claims paid as well as zero paid claims. The claims data file is normally received by HCCI within 2-3 weeks of the original request and the signature of non-disclosure agreements.
Work with the client to obtain information as outlined in the audit implementation list prior to the receipt of data file from the claims administrator. HCCI may ask for specific eligibility information on specific members prior to or during the onsite review.
Upon approval of the claims data file by HCCI, the onsite validation review is scheduled with the claims administrator.
Review the client’s plan documents and other information in preparation of audit.
Upon receipt of the claims data file, HCCI will perform a data conversion and verify the total claims and dollars with the file control numbers. Custom designed programs and queries will be utilized in the stratification process to review 100% of all claims. Claims will be selected based on the approved sampling methodology. Most often the methodology is stratified random, judgmental, or a focus audit sample. All claims selected will be reviewed as well as all other claims for those particular member/dependents and associated providers. This aspect of auditing sets HCCI apart from other auditing companies. HCCI does not perform a random selection of claims and review each of those claims as a single claim without consideration and comparison to the total population of claims.
Upon completion of the editing or stratification procedures, the claims will be selected and submitted to the claims administrator.
To validate the claims selection, programs will be written specifically to ensure that the claims selected are accurately processed and paid according to the plan and contract provisions. Programs that will be written but not limited to include:
Assists the client in requesting the processed claims data from the claims administrator for the approved audit scope. The data file will include all claims paid as well as zero paid claims. The claims data file is normally received by HCCI within 2-3 weeks of the original request and the signature of non-disclosure agreements.
Work with the client to obtain information as outlined in the audit implementation list prior to the receipt of data file from the claims administrator. HCCI may ask for specific eligibility information on specific members prior to or during the onsite review.
Upon approval of the claims data file by HCCI, the onsite validation review is scheduled with the claims administrator.
Review the client’s plan documents and other information in preparation of audit.
Upon receipt of the claims data file, HCCI will perform a data conversion and verify the total claims and dollars with the file control numbers. Custom designed programs and queries will be utilized in the stratification process to review 100% of all claims. Claims will be selected based on the approved sampling methodology. Most often the methodology is stratified random, judgmental, or a focus audit sample. All claims selected will be reviewed as well as all other claims for those particular member/dependents and associated providers. This aspect of auditing sets HCCI apart from other auditing companies. HCCI does not perform a random selection of claims and review each of those claims as a single claim without consideration and comparison to the total population of claims.
Upon completion of the editing or stratification procedures, the claims will be selected and submitted to the claims administrator.
To validate the claims selection, programs will be written specifically to ensure that the claims selected are accurately processed and paid according to the plan and contract provisions. Programs that will be written but not limited to include:
- Payment and Charge duplications
- COB – Program to identify and review for accuracy all claims processed with other insurance.
- Member eligibility – Comparison Analyses
- Plan Application of Deductibles/Copayments/Coinsurance/OOP/Stoploss
- Provider Network Discounts and Application of Payments
- Timely Filing Within Limits Outlined in the Plan
- Third Party Liability to include Workers Compensation and Accidents
- UCR Rates for Non-Par Providers
- Exclusion Programs to Cover all Exclusions Outlined in the Plan
- Credit/Refund Program to Review Denials and Recovery Codes
- Review of all Members over 65 years of age to review employee status
- DRG Review to Determine accuracy in classification and payment.
- Service Limitation Program – For all services with Plan limits.
- Surgery Coding – Review of all surgical procedures to include Surgeon, Assistant Surgeon, Surgical Assistant, Co-Surgeon, Anesthesiologist, and CRNA
- High Dollar/Volume Contracts
- Comprehensive review of all ESRD and transplant cases
- Claim turnaround time – to determine compliance with Plan guidelines.
Submit the claims selection to the claims administrator for the purpose of retrieving data necessary to conduct the onsite audit and to set up system access for all claims processing applications.
Work with the claims administrator to resolve all outstanding audit rebuttals /claims issues.
Submit the draft report to the claims administrator and finalize all outstanding issues. A draft copy will also be forwarded to the client. HCCI will follow-up throughout the rebuttal process to ensure that all recoveries are credited to the client.
Timetable
The estimated time involved in the audit project is based upon the claims administrator’s timely submission of the data file, open dates for the onsite audit, and the final resolution of audit issues. Normally, an audit of this type is completed within 90-120 days from the original notification date to the Plan Administrator. HCCI works diligently with all parties to be responsive to all deadlines and audit requirements.
