Our experience with payers allows us to conduct self-insured employer reviews much more efficiently and effectively.
Seneca Consulting Group worked for, and with, many of the major healthcare insurers in this country. Our experience with payers allows us to conduct self-insured employer medical auditing reviews much more efficiently and effectively. Because we review the entire dataset of claims, rather than just a sampling, we are able to target specific areas of concern for review with the payer. This also allows us to identify the root causes of claim errors so that our clients can minimize future claim overpayments. Our data warehousing and plan modeling service provides our clients with access to detailed claims information and unbiased trend projections. In addition to our operations and technology expertise, we have a diverse staff possessing comprehensive healthcare skill sets upon which to draw, should the project require it. We have professionals with experience and credentials in clinical coding, nursing and healthcare finance. The breadth of our professional expertise allows us to identify more complex issues in claims payments as well as devise operational solutions to prevent future occurrences.
During this process, Seneca Consulting Group remain sensitive to the relationship between an employer and its Third Party Administrator and works to minimize the amount of resources required by the latter. In addition, we are often able to work with the Third Party Administrator to create operational improvements that benefit both the Third Party Administrator and our client.
Our approach is different from that of most auditors in that we do not utilize a sampling methodology. Seneca Consulting performs a comprehensive review of all paid claims, using our electronic capabilities and proprietary claims audit logic. We are confident that a comprehensive review is superior to a sampling methodology because it identifies all incidences of a particular type of payment error, allows for the payer to validate the findings of the audit based on specific claims information, and provides more convincing evidence of operational issues at the payer site to facilitate process improvement and prevent future occurrences.
- Obtain a full data set of claims paid for the last 18-24 months.
- Gather information on benefits, eligibility, claims processes, provider contracts, and plan designs to apply in our algorithms.
- Systematically review the data set, using standard and ad hoc queries.
- Work with the Third Party Administrator to confirm logic used in overpayment reports.
- Identify process improvement opportunities to minimize future errors.
- Work with employer and Third Party Administrator to plan recovery of overpaid claims.
- Focus on retraction efforts to minimize lag in recovery and increase percent realized.
- Monitor recovery performance to ensure overpaid claims are recovered.
- Use reports and modeling to resolve any other issues found in audit.
- Recommend actions that can improve client satisfaction with Third Party Administrator.