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North Jersey IIA Software Expo Data Mining-driven Eligibility, Dependent Eligibility and Claims Auditing May 17, 2007. Contents. Introductions and Overview The Business Case Audit Survey Responses and Case Studies Web-based Technology Next Steps. Introductions and Overview.
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Eligibility, Dependent Eligibility and Claims Auditing
May 17, 2007
Web: Eligibility Auditing
Case Management Audit
Clinical and Disease Management Audit
* Excludes recoveries from payor
** Includes a 2% reduction in spend plus a 10% trend
*** Includes a 3% reduction in spend plus a 10% trend
Why Perform an Audit?
Which Medical Areas Should Be Audited?
Which Rx Areas Should Be Audited?
What Are The Top Attributes?
Eligibility Dashboard Example
Plan statistics as well as query summaries are provided in the Dashboard Summary
Users can refine the standard query selection criteria by changing the search criteria
The query result can be easily downloaded to Excel for further analysis
Beyond Termination Example
In this example we looked for claims greater than $200 and term dates after Sept. 1, 2005
Low Premium Example
This query identifies tier mismatch suspects
Dependent Confirmation Web Page
Employees are presented their dependents and are asked to confirm eligibility
Alternatively, employees can be prompted with “fill-in-the blank” questions regarding their dependents
Employees can be asked questions about spousal employment and their respective benefits insurance or questions regarding their college age child to ensure eligibility
Dependent Audit Dashboard - 24/7 ROI
Member activity metrics are available
24/7 via the web
The actual savings based upon claim
spend is available 24/7 via the web. Savings
Also be computed on a per-capita basis
The actual savings by relationship
type is available 24/7 via the web
Departmental Healthcare Spending
Our system also helps users understand member spend by organizational unit
Howie Gerver at 201.891.8010 or, Howie@HRBestPractices.com; or
Ed McDermott at 201.818.9196 or Emcdermott@HealthCostSolutions.biz