Broker Payment Integrity Solutions: How You Can Add Compelling Value

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How You Can Add Compelling Value


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Self-insured employers are searching for ways to slow the rapidly increasing costs and risk in health benefit plans. A broker of record (BOR) can deliver guaranteed return on investment (ROI) and other compelling value to self-insured employers through the strength of HMS payment integrity solutions.


A guaranteed return on investment

Large insurance carriers that enter administrative service only (ASO) agreements with employer-funded benefit plans aren’t in the business of risk mitigation, cost containment or compliance verification. The sponsoring employer bears the risk from claim errors and abuse, inefficient plans, and the costs that increase year-over-year.

As a BOR, you can provide the services to fill the gap. By offering waste-mitigation and medical plan audit services from HMS, you can deliver badly-needed cost reduction options to self-insured employers while reducing the risk associated with compliance errors.

We find and fix the causes of financial drain and risk where they begin: through errors on claims, improper billing, benefit claims abuse and fraud, ineligible beneficiaries, and inefficient medical plans.

The ROI is clear, as is the service advantage that ASO agreements can’t touch.


The solutions

HMS’s solutions deliver an improved cost and risk picture for self-insured plans through tangible and measureable methods that eliminate improper payments before and after claims are paid, finding errors and verifying dependent eligibility, detecting patterns of abuse or other improper billing trends, verifying ERISA compliance, and eliminating systemic spending problems – to name a few.

These payment integrity solutions include:

  • Dependent Eligibility Verification. By uncovering the hidden cost to a plan created by ineligible dependents, Dependent Eligibility Verification can deliver a typical return on investment beyond 400%. HMS handles verifications sensitively to ensure employees understand every step in the process and why a dependent may be ineligible.
  • Working Spouse Provision Verification. Remove the cost of covering a plan participant’s working spouse with a two-step process: conduct a verification of spouses with coverage available from their own employer, and by adding a surcharge for those who choose to remain in the employer plan.
  • Claim Edits and Analytics. Using the broadest range of pre- and post-pay edits to review claims for error and potential abuse, Claim Edits and Analytics create claim-level breakdowns of improper billing issues and statistical/anomaly pattern analysis to help spot suspicious trends.
  • Clinical Claim Review. Covering Diagnosis Related Group coding, medical necessity, reimbursement methodology, covered vs. non-covered services, readmissions, level of care and others, HMS Clinical Claim Review helps payers avoid many types of errors.
  • Medical Plan Audit. Claims administrators sometimes pay providers more than the contracted rate or pay a claim multiple times. There can be legal compliance gaps or systemic spending problems. A Medical Plan Audit will find – and fix – problems that create an inefficient health plan.


Taking it to the customer

Because large carriers are primarily focused on their at-risk (fully funded clients), self-insured employers must look for ways to reduce risk and stop the endless cycle of increasing cost. HMS knows this space – the company has provided risk and cost mitigation to large insurance carriers and the plans they manage for years. Now we’re offering the same advantages to self-insured employers. By offering these services to your current and potential clients, as a BOR you have an opportunity to provide unusual value that sets you apart from the competition.


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