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Product:

Health Plan Audit Services

Vendor:

HMS Employer Solutions

Additional Information:

HMS Employer Solutions creates immediate measurable value for employers by protecting the financial vitality of their health plans. We are part of HMS, the nation’s premier healthcare cost containment expert. As a result of our services, our clients recovered over $2 billion in 2011, and saved clients billions of dollars more through prevention of erroneous payments.  The following menu of audit tools will be available to the PEBA membership at competitive Alliance purchasing rates:

  • Dependent Eligibility Audits (DEAs) is a proof based audit to verify that dependents are truly eligible for coverage. After performing this type of audit, employers typically find that 4-8% of enrolled dependents are ineligible. HMS will guarantee a positive return on Investment for DEAs. Typically ROI’s ranges from 500% to 1500%. Additional add-on: Employee Eligibility, Spousal Affidavit, Point of Enrollment Dependent Eligibility check.
  • Medical Claims Compliance Audits to ensure that members’ Claims Administrators are paying claims appropriately. Claims can be paid in error for many reasons, including duplicate billing, claims coding errors, or failure to coordinate benefits when a third party is liable for payment. By reviewing 100% of claims, HMS identifies inconsistencies within the processing and payment of medical and dental claims.
  • Inpatient Bill Audit Services to identify unnecessary spending of healthcare dollars by verifying that charges billed by hospitals match the actual care and services provided. Auditors compare itemized bills to medical records to verify that services billed were ordered, documented as received, and reimbursable per billing guidelines. HMS’s medical bill audits typically result in recovery of 2-4% of claims costs.
  • Pharmacy Audits, including audits of rebates, retail pharmacies, and Pharmacy Benefit Managers to help control pharmacy costs by identifying and recovering improper payments, while identifying potential fraud, waste and abuse.

Please refer to the Health Plan Audit Services Alliance Alert for additional information.

Dependent Eligibility Review: City of La Porte, Texas Case Study
After discovering inconsistencies in how employees were allowed to enroll or terminate coverage, The City of La Porte, Texas (hereafter referred to as “The City”) decided to conduct an internal audit of all 450 eligible employees. The audit determined that some of the 659 covered dependents were not eligible under the plan’s definition of eligible dependent… click here to read more.