Claim Recovery and Overpayment Audits

Health Decisions combines electronic analysis with expert review of paid claims to identify claims that are the responsibility of another party. Our Claim Recovery Service is comprehensive and screens 100% of paid claims in over 40 Recovery Modules. Recoveries are then sought from the appropriate third party to maximize a strong return on investment.

Paperless Claim Recovery (PCR) Software Suite

The same software suite we use is available for use by plan administrative staff. This tool has increased post-payment case processing efficiencies 30-fold. (A processor using PCR can process in one day the same number of cases a processor using traditional methods would take a month to do).

Enrollment Audits

1. Dependent Eligibility Audit: A Dependent Eligibility Audit combines mailing and communication technology to verify the eligibility of dependents enrolled in an employer’s health plan. Removal of dependents not eligible for coverage has a positive impact on a company’s bottom line without changing coverage.
2. Verification Audit & Survey: This Audit begins with a customized pre-populated survey form detailing health plan enrollment information available for all employees. These surveys capture and identify new information including: ineligible members; address changes; and other insurance coverage.
3. Enrollee Audit: An electronic comparison of an employer’s HR/payroll system information to an employer’s health carrier’s eligibility information. These audits often identify significant gaps in eligibility information that result in retrospective and future savings in claim costs.

Data Mining/Warehousing