Most claims never get checked. That is where the waste hides.
Medical and pharmacy claims are paid on trust far more often than employers realize. On a fully insured plan that is the carrier’s problem. On a level-funded or self-funded plan it is yours, and nobody sends you a notice when a claim is paid twice, priced outside the contract, or billed for a service the plan excludes.
The same three patterns, at almost every group.
Payment integrity work is unglamorous and specific. It looks at individual claims rather than at the loss ratio, which is why it finds things a renewal analysis never will.
Duplicates and rebills
The same service paid twice under slightly different codes or dates, or a corrected claim paid alongside the original. Routine, recoverable, and invisible in aggregate reporting.
Contract-rate mismatches
A claim paid at a rate the network contract does not support. Finding these requires comparing the payment against the contract, which is exactly the comparison nobody performs by default.
Eligibility and coordination errors
Claims paid for people who were not covered on the date of service, or paid as primary when another plan should have paid first. The same upstream eligibility problem that causes wrongful denials also causes wrongful payments.
Hospital prices vary more than quality does.
Published research on hospital pricing gives employers something they never had: an external reference point. Analysis of commercial claims has found private plans paying hospitals in the region of two and a half times what Medicare pays for the same services, with wide variation between facilities in the same market.
Network cost and quality data
We push carriers and vendors for real cost and quality data by provider rather than accepting a network’s reputation as the whole story. Transparency requirements have made more of this available than most employers use.
Where the steering is worth it
When a facility in the same network costs several times another for the same procedure, plan design and employee guidance can move volume without restricting anyone’s care.
Reference-based pricing, honestly
A reference-based approach can change the arithmetic considerably. It also changes the employee experience, and both belong in the decision. We advise on it case by case rather than placing a program.
A finding is worthless until somebody acts on it.
Recovery, not a note for next year
When an audit finds a pattern, we pursue the correction and hold the vendor to it rather than filing the observation for the renewal meeting.
Billing reconciliation every month
The carrier invoice checked against enrollment so the error is caught in the month it happens, when it is still a correction rather than a negotiation.
Reporting you can act on
Claims, pharmacy and stop-loss data in one view with outliers flagged, so the audit question is asked during the year rather than after it.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Bloomfield Hills, MI 48304
248.370.8853
719.425.2649
281.404.5670
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