“Time is money.” Benjamin Franklin coined this phrase when he wrote his “Advice to a Young Tradesman” in 1746. He said, “Remember that time is money. He that can earn ten shillings a day by his labour, and goes abroad, or sits idle one half of that day, tho’ he spends but sixpence during his idleness... has really spent or rather thrown away Five Shillings besides.”
Makes sense, right? If you’re not using your working time to earn money for your organization, you are, in effect, costing them money. And since you’re interested in completing a healthcare claim audit, you understand that time is of the essence and you want to know just how long the process will take. Here, ‘Time is Money,’ so the quicker you complete the audit, the faster you can stop any leaks of your self-funded plan. And the sooner the audit is completed, your team can get back to work to concentrate on their daily tasks and what’s at hand.
Just how long does a medical healthcare claim audit take?
To answer, we’ll examine the typical 120-day timeline of our most popular audit, a CTI comprehensive audit with continuous quality improvement, by looking at some of the milestones you can expect after the agreement is signed and we are ready to begin. .
- Kick Off Meeting (First Day) – Typically, this meeting takes place on the phone, and it ensures that everyone – the administrator, the client and CTI – is on the same page. A full overview of the audit process is presented, pertinent documentation is requested, and all of the plan sponsor’s rules and objectives are completely detailed.
- Data Collection (Approximately Two Weeks In) – During this stage of the audit, CTI collects information from both the plan sponsor and administrator. Information requested from the administrator includes data such as historical enrollment and the medical claims from the date range agreed upon as well as the processes they use for claim processing, in particular, the process used to handle the plan sponsor’s claims when different from standard It is also critical that we gather information from you such as plan design documentation and historical data specific to the audit. This allows us to compare against the documentation your administrator is using to ensure they are following the plan’s guidelines.
- Operational and Benefit Plan Review (Approximately Two to Three Weeks In) – Before we begin to determine your administrator’s proficiency, we learn about how it operates. Our information gathering starts by having the administrator complete an operational questionnaire which gathers information like claim administrator information, claim adjudication, eligibility procedures and HIPAA compliance. Another key component of our pre-audit information gathering is the review of how the plan’s claims should be administered. This enables our staff to have a thorough understanding of the provisions detailed in the plan.
- Random Sample Audit (Approximately Three Weeks In) – Run in parallel with our electronic screening, we perform a stratified random sample audit. This audit provides overall performance against key indicators such as financial accuracy and enables benchmarking of claim administration quality and quantification of the savings potential based on improved administration accuracy.
- Electronic Screening and Analysis with Targeted Sampling (Approximately Three Weeks In) – Using our proprietary electronic screening and analysis software, we screen 100% of every service line processed during the audit period. This process identifies potentially recoverable overpayments and costly system programming problems. Those problems are in turn analyzed to test the suspected errors. These can include identification of systematic problems in high-control risk categories and recoverable overpayments as well as immediate remedies of leaks and problems.
- Onsite Audit (Approximately 8 Weeks In) – This step usually takes place at the administrator's offices. It is here where we validate the possible overpayments, underpayments and system errors. Throughout this section of the audit, we will present any potential errors to the TPA or insurance carrier to review and provide us feedback on. Once feedback is provided, we begin work on the first draft of our audit results.
- Reporting (Approximately 9 Weeks In) – This process takes place after the audit of claim files. We provide the administrator with our feedback in writing and allow them time to validate or refute the possible errors. Once they reply to us in writing, and all information has been exchanged, CTI will either remove the error because it has sufficiently been demonstrated that the claim was processed correctly – or the error stands. Either way, we inform the administrator and include this information in our final written reports so that specific type of error can be addressed and potentially avoided in the future.
- Presentation of Audit Results – At the conclusion of the audit, we present detailed reports of the audit findings. The presentation covers both summary and detail level reports, result analysis and statistically-supported recommendations. CTI’s deliverables are industry-leading interpretations and displays of audit results. They are instrumental in building consensus, encouraging action to address problems and establishing a higher standard of administrator accountability.
Following delivery of the audit reports and resolution of any open issues, we pride ourselves on being available to assist you and your plan sponsor by working with the administrators on addressing the problems and cost-saving opportunities.
For a full listing of our services, please click here. To download our FREE "Get The Full Picture" white paper for a thorough look at comprehensive medical claim audits, please click on the graphic below.
