Healthcare 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, claim-payer errors, medical errors, misrepresentation of health conditions, unenforceable and unauditable contractual provisions, and finally, an overall lack of internal controls.

Due to today's complex healthcare issues and ever-increasing medical costs, relying solely on traditional in-house or third-party review is simply not cost-efficient.

The CRS 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 claims experts, CRS stands as the leading one-source provider of claims 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 then evolve to utilize the full scope of the program over time for maximum and sustained benefits. Cash savings and future healthcare savings are generated through 3 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 2-5% 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 prospectively as well as cost recovery on overpaid claims.

Contract Analysis, Operational Reviews, and Recommendations

An independent and objective assessment can be initiated from several different starting points. For example, a review of the claims-processing practices and procedures is conducted during the claims-recovery process to evaluate administrative and claims-policy compliance, assess performance standards, and identify processing issues. Our analysis can assist benefits administrators in measuring program performance and monitoring ongoing effectiveness of cost-containment initiatives and benefits changes. From the employer's perspective, a review may involve controls in the management of vendors that impact the delivery of third-party services. Finally, from the employee perspective, we also have tools to help the frontline in making decisions that ultimately will impact the initiation of claims.

Ongoing Prospective Savings

We provide our clients ongoing surveillance of claims activities. We also provide pre-implementation audits if a new vendor is selected for claims processing. Finally, we provide periodic audits for testing internal controls as well as onsite training of internal audit staff. In some cases, we co-source with internal audit staff for more complicated audit tests.

CRS prides itself on being as noninvasive as possible, and we generally require only minimal resources to begin. Trained experts examine and review 100% of your past transactions. All services in connection with the audit are provided by CRS team members, including our subject matter experts and our recovery staff. We strive to ensure quality and minimize disagreements. Our flat fee schedules and performance-based compensation is driven on results and calculated on a share of the savings that our services generate. We are committed to being your partner in ensuring the financial integrity of your medical claims!