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 Auditing Services
Areté works with their clients to ensure their medical claims administrator and pharmacy benefit managers are effectively managing their health care costs. Employers continue to experience a substantial deterioration in ability or willingness on the part of claims payers to correctly adjudicate their claims and control their costs through prudent and proactive claims management. Through our audits, we review the carrier’s clinical and financial protocols against the client’s benefit program and industry standards.
Medical Management Audits
As health care costs continue to rise and traditional cost containment methods are exhausted, employers are beginning to ask the question “does my medical management program effectively identify and intervene with those members driving the majority of health care costs?”
Areté’s medical management audits identify operational strengths and weaknesses, as well as measure the effectiveness of current programs in managing health care outcomes and costs. Medical management audits frequently reveal missed opportunities and performance problems that result in avoidable medical expenditures.
Our audits frequently reveal missed opportunities and performance problems that result in avoidable medical expenditures, such as:
- Ineffective nursing interventions
- Minimal or no intervention from the health plan medical directors
- Lack of timeliness in concurrent reviews and discharge planning
- Missed case management opportunities
- Undetected large-dollar outpatient claim
- Outdated quality of care protocols
- Deficient data tracking and reporting
- Lack of performance guarantees and the corresponding metrics
Medical, Dental and Large Claim Audits
If you are an employer with a self-funded medical plan, you are essentially handing your claims administrator your checkbook. Given the magnitude of medical claim costs, it is critical to determine if your plan funds are appropriately distributed. While it has always been a sound business decision to audit your claims administrator, the recent focus on corporate responsibility (e.g., Sarbanes-Oxley) further supports the need for periodic audits.
Most companies, both large and small, do not have proper measures in place to confirm that their medical plan funding is being handled properly and at its best. Medical claims are often overpaid, are paid for services not covered by the provided plan, or are paid for patients who are no longer eligible for such coverage.
All large experience rated and all self-insured employers (regardless of size) require assurance that their plan administrators are consistently paying medical claims accurately and appropriately, according to plan design and terms of the administrative agreement. To achieve this goal, Areté conducts a comprehensive review of plan administration, including paid claims and provider discounts.
Prescription Audits
 Each year, your group health plan pays for thousands of prescription claims. Yet without a pharmacy plan audit, employers are unaware if they are being billed correctly by their Pharmacy Benefit Manager (PBM) for the prescription claims. Correct billing, improper use, and mounting problems are oftentimes unknowns, as well as, medication errors, incorrect discounts, and mistaken dispensing fees.
Self-insured employers need assurance that PBM's pay prescription drug claims accurately and appropriately, according to formulary and terms of the administrative agreement. To achieve this goal, Arete conducts a comprehensive review of PBMs including a claims audit and rebate audit to provide clients with the following:
- Determine compliance with both contract terms and plan documents.
- Assess financial accuracy of paid claims and administrative processes, including error and fraud detection.
- Evaluate accuracy of payments and identify overpayments, duplicates cost savings prospects.
- Identify control weaknesses, their causes and suggest process enhancement/cost savings prospects.
- Assess retail and mail order programs.
- Review client's role regarding administration and offer recommendations.
- Identify, validate, and recover overpayments.
Unlike most of our competitors Areté provides an impartial review of your PBM options. Areté has not created and will ever attempt to steer our clients into one of these so called proprietary “purchasing coalitions.” These “purchasing coalitions” between our competitors and national PBMs are often just another undisclosed source of revenue for both entities.
Eligibility Audits
All large employers 1000+ employees should conduct a Eligibility Audit at minimum every three (3) years. This is a valuable method for which large and self-insured employers can effectively qualify that only eligible employees and dependents are receiving coverage under their health, dental and prescription plans. By identifying and removing former and ineligible dependents with a Eligibility Audit saves employers administrative costs, prevents filing of erroneous claims, and improves the renewal process by ensuring that accurate demographic data is utilized to determine correct employee and dependent eligibility.
When conducted, the Eligibility Audit reviews an employer's entire insured population or targets a specific high-risk group, such as different last names, common law spouses, domestic partners, full-time students, and others. Our Eligibility Audits typically uncover former employees that are still receiving benefits under your plan and significant numbers of ineligible dependents, usually aged-out college students or divorced spouses, which oftentimes produce in a considerable savings for employers in annual premium costs.
Areté's eligibility audit entails a review of the medical, pharmacy, and dental claims administrators’ eligibility records to uncover the following:
- Untimely administration of additions and terminations
- Poor administration of new hire waiting periods
- Poor administration of over-age dependents and full-time student status
- Lack of coordination between medical and pharmacy benefits at time of termination
Hospital Bill Audits
 Hospitals often charge patients for services, medications, and supplies before they are actually received, that were not received or even bill duplicate charges. Frequently there are data entry errors due to complicated or inefficient billing systems in hospitals. Other times there is change in the doctor's orders or an early discharge from the hospital that can effects the accuracy of the bill. These are just a few of the reasons why hospital bill charges may be deemed inappropriate.
Areté's hospital bill audit program is an effective method for self-insured employers to save money and monitor large dollar claims. With our auditing service, our auditors review line items and document inappropriate charges on a retrospective basis to determine appropriateness of charges and identify over-payments. In addition to our veteran audit team of nurse auditors, we often utilize a nationwide network of experienced nurse auditors who go on-site to the hospitals to perform chart audits. Records are reviewed and validated and charges are corrected based on the actual services when necessary. Additionally, cases are checked for contractual compliance, corrected reimbursement amounts are identified with all findings documented and submitted in a final report.
Overpayment Recoveries
Areté takes additional steps to ensure full recovery for any overpayment our clients. We work directly with providers to increase the recovery of payments for claims that a third-party has reimbursed. Additionally, Areté negotiates and monitors recovery collection activity to ensure all recovered dollars go to our client. By taking these steps and identifying these errors and cost savings, clients are also able to lower medical loss ratio, lessen provider appeals, and increase earnings per share. These services are available from Areté on either a percentage of recovery or hourly fee basis. |
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