Making a layer cake is deceptively difficult. And if you are making a cake for someone else, the pressure is really on.
What if you don’t understand the recipe or it has unfamiliar ingredients?
If you accidentally use salt instead of sugar, baking powder instead of baking soda, or whole eggs instead of egg whites the results could be disastrous.
If you don’t mix your ingredients enough your cake could be flat, but if you mix them too much the components could separate.
Your oven could be too hot or not hot enough.
Then even if everything goes right and you bake beautiful layers, you still have to assemble and ice your cake.
If you don’t let the layers cool long enough the icing will melt. Your layers must align perfectly, or your cake could topple. And no matter how delicious your cake is, the wrong icing can ruin it, leaving your customer or family unhappy.
Being a health benefits plan administrator is like making a layer cake. It’s up to you to understand what features your plan should have with the right mix of limitations and exclusions. You don’t want your benefits to be too rich or too sparse. Your plan documents must reflect those benefits in a way your members can understand, and finally, you need an administrator that can accurately translate the benefit plan and provide your members with superior customer service.
Like many layer cakes, your health benefits plan has three layers.
Your plan benefit features are the ingredients; the dollar amounts, limitations, and exclusions are the measurements that create your recipe.
At the base of your cake is your plan benefit intent. Beyond the features you’ve chosen, what is your intent for things like assistant surgeon reimbursement? Do you want in-network and out-of-network claims to be subject to the same claim edits? Do you want the term “benefit maximum” to refer to the maximum paid amount or to the maximum allowed amount?
Your cake’s second layer is your plan documentation. Do your plan documents reflect your intent? Are they clear and concise yet comprehensive?
The actual administration of your plan is the cake’s third layer. This is the way your claims are paid, how eligibility is managed, and how things like subrogation and appeals are handled.
The icing on the cake is the customer service your plan members receive; it makes or breaks your cake.
At CTI we help our clients ensure they provide their members with a perfectly baked, structurally sound, and beautifully iced health benefits plan layer cake.
Our fully-automated, comprehensive major medical audits examine your plan’s benefit intent, documentation, and administration to determine if they align with each other. Our Plan Documentation Analysis looks at your benefits recipe to make sure it is complete and clear. Our Random and Targeted Sample Analyses and our Operational Review Questionnaire examine your plan’s administration, and our Fraud, Waste, and Abuse Analytics identify potential savings opportunities. Because our audit philosophy is continuous quality improvement, we’ll help you identify ways to make your health benefits plan even better. And that’s icing on the cake.
Contact us today for a quote and start making your health benefits plan a little sweeter.
