Healthcare Horizons: Approach

Our approach is different from most vendors in that we do not utilize a sampling methodology. Healthcare Horizons performs a comprehensive review of all paid claims using our electronic capabilities and proprietary claims audit logic. We are confident that a comprehensive review is superior to a sampling methodology because it:


	identifies all incidences of a particular type of payment error,
	allows for the payer to validate the findings of the audit based on specific claims information, and
	provides more convincing evidence of operational issues at the payer site to facilitate process improvement and prevent future occurrences.


	Obtain a full data set of claims paid for the last 18-24 months

	Gather information on benefits, eligibility, claims processes, provider contracts, and plan design to apply in our algorithms

	Systematically review the data set using standard and ad hoc queries

	Work with the Third Party Administrator to confirm logic used in overpayment reports

	Identify process improvement opportunities to minimize future errors

	Work with employer and Third Party Administrator to plan recovery of overpaid claims

	Focus on retraction efforts to minimize lag in recovery and increase percent realized

	Monitor recovery performance to ensure overpaid claims are recovered

	Use reports and modeling to resolve any other issues found in audit

	Recommend actions that can improve client satisfaction with Third Party Administrator