Case Study: Elevating Healthcare Claim Payment Accuracy

Executive Summary

In response to growing concerns about the accuracy of healthcare claim payments, a prominent national multiemployer plan sponsor, faced challenges related to uncertainties in claims accuracy, non-standard benefit designs, and financial risks due to overpayments. To address these issues, Withum worked with the client to design and implement a strategic approach that included a meticulous risk assessment, a comprehensive review of 100% electronic claims data, focused claims audits, and strategic negotiations with its third-party administrator (TPA). Through skilled negotiation and resolution, the client successfully reached a settlement with the TPA, recovering $2.1 million in rightfully owed funds.

The Client

A National Multiemployer Plan Sponsor.

The Challenge

The client has been facing several challenges with their healthcare plan. Firstly, the lack of transparency regarding plan cost increases eroded their trust in their service providers. Secondly, uncertainty surrounding their claims experience further complicated their ability to manage costs and plan effectively. Thirdly, concerns about the adequacy of plan funding weighed heavily on the client’s decision-making. Finally, the unpredictability of claims created financial vulnerability, affecting the client’s financial stability. These issues have made it difficult for the client to navigate their healthcare plan and manage their finances effectively.

The Approach And Solution

Withum initiated discussions with the plan sponsor and key stakeholders. Building on our insights and past history with the TPA, we collaborated with the plan sponsor to craft a strategic approach. The goal was to methodically identify and validate the issue, ensuring a well-informed process that would lead to the best possible outcome.

The following outlines our approach:

  • Risk Assessment and 100% Electronic Claims Review: We initiated a meticulous risk assessment, accompanied by a comprehensive review of 100% electronic claims data. This step laid the groundwork for our subsequent actions.
  • Focused Claims Audits: Leveraging findings from the risk assessment, we conducted targeted claims audits, pinpointing specific instances of improper payments related to plan benefit exclusions.
  • Negotiation and Resolution: Armed with a robust understanding of the issues, we assisted the client with strategic negotiations that resulted in a settlement with the TPA and corrective action to rectify the problem.

The Results, ROI

  • Identification and Validation of Improper Payments: Through rigorous testing, we identified and validated numerous instances of improper payments, specifically related to plan benefit exclusions. These findings illuminated the path to resolution.
  • Successful Settlement: Our understanding of the issue, skilled negotiation, and resolution efforts culminated in a successful settlement that addressed the identified issues and recovered funds for the client.
  • Enhanced Financial Stability: By rectifying payment inaccuracies and aiding in the recovery of $2.1 million in rightfully owed funds, we bolstered the plan’s financial stability.

Withum’s efforts led to the identification and validation of numerous improper payments, particularly related to plan benefit exclusions. Through skilled negotiation and resolution, the client successfully reached settlements with the TPA, recovering $2.1 million in rightfully owed funds. This not only rectified payment inaccuracies, but also enhanced the financial stability of our client, mitigating the strain caused by overpayments.

The overall return on investment for the client was strong at 13:1, highlighting the effectiveness of our strategic interventions and their positive impact on the client’s financial well-being.

Contact Us

For more information or to discuss your business needs, contact Withum’s Self-Insured Health Plan Advisory Services Team.