Total time: approximately six weeks
Step One: The Data
The Plan Administrator designates the scope and time length of the retrospective claim analysis.
The Health Plan Navigatortm solution is flexible and is customized for each project. We then request the Plan Administer fill out a questionnaire and supply the standard schedule of benefits, full plan language, reinsurance contract, benefit calculation codes, override and adjustment codes, and reason codes, HR staff practices and experience, and other liability histories and reports.
We then require all claims data in electronic format with all fields identified in a compatible data base management program, such as Access or Excel. We can also review paper claims.
Step Two: Compare
We compare the TPAs policies and procedures to the industry standard. We do this to identify and recommend improvements in standard plan provisions and practices including:
- Pre-existing Condition Limitations>
- Medical Necessity Determinations
- Clinical Review of Pre-certified Visits
- Physical Therapy vs. Maintenance Therapy
- Premiums Waivers, Benefit Extensions and Coordination
- Standards of Clinical Practices for Chemotherapy and IV Infusion, Radiation Therapy, Dialysis, Organ Transplant Administration
- Interpret and Recommend Modifications of Standard Third Party Contracts, including provider networks, prompt pay, transplant networks, PBMs, PPO, Case Management, etc.
Step Three: Compliance
We examine 100% of claims with our proprietary software to uncover individual provider (CMS-1500) and other irregular claim patterns or unbundled claims requiring an on-site audit. All UB-92s in excess of $10,000 are reviewed with claim copies.
Claims are then cross-checked for compliance with contract terms, plan documents, and beneficiary demographics. We then assess for inaccurate payments, duplicates, and other errors.
Areas that require individual on site audits are identified.
Step Four: On-Site
We perform an onsite examination of your utilization management, case management, eligibility data, and other policies and procedures with the assistance of your staff.
All paper claim audits are completed.
A comprehensive Report is created and presented to the carrier and the CEO quantifying discrepancies in three areas: adjudication, administration and re-pricing, and specifically identifying TPA processes and procedures proved unsuccessful during the review process.
Step 5: Recovery
HPN and Ethicare will send initial claim recovery letters to providers and insured’s at the Plan Administrator’s discretion. Non-compliant providers are compelled to meet the terms of their contracts. Remaining recovery efforts are transferred to the TPA for completion.
