The greatest potential for cost reduction and containment is achieved through aggressive claim recovery coupled with eligibility enrollment verification. Verifying enrollment will produce far greater savings than ever can be realized by beefing up your claims recovery process.

“The real solution to claims recovery loss is always identified through enrollment verification steps,” explains Si Nahra, Ph.D., founder and president of Health Decisions, Inc., in Plymouth, MI.

Health Decisions always identifies a significant number of recoverable claims that slip through the system and then follow up to return the money to its client. But the firm’s greater success is in identifying missing enrollment data so that claims are paid correctly the first time.

“During our initial contact, very few of our prospective clients are convinced that the money we will save them with our enrollment verification service will exceed the significant amounts of money we will help them save in claims recovery,” adds Nahra. “But after experiencing our revolutionary and pioneering Post Payment Administration system almost all our clients become convinced we are correct in making this assertion.”

Health Decisions, Inc. is the first and only claims recovery firm involved in Post Payment Administration. “After everyone else is finished,” says Nahra, “we apply our expertise, methodology and powerful software tools and dig even deeper to uncover more money for self-insured companies and health insurance companies.”

Enrollment Reconciliation, when done properly, involves a comprehensive review of enrollment information to eliminate ineligibles, correct payor errors, and update enrollment records to reduce costs and legal liabilities. The key areas surveyed include coordination of benefits, any unknown divorce decree, existence of Medicare coverage, and dependent status of family members.

Health Decisions, Inc., offers an employer or insurer use of its specialized staff to handle all the logistical details associated with an Enrollment Verification Survey of all covered persons. The survey is sent to all employees, retirees, spouses, and dependents to get the full range of information needed for claim administration and regulatory compliance. For more than 10 years Health Decisions has achieved response rates of 90 percent on its purely voluntary surveys.

Enrollment verification generates new information that can identify recoveries that otherwise would go undetected by:

• Reconciling a company’s Human Resource files with payor records to eliminate ineligible employees.
• Reconciling multiple plan or payor rosters to eliminate duplicate enrollments.
• Surveying enrollees and covered members to refresh out-of-date data and collect new facts that identify previously unknown recovery opportunities. A survey properly done can double the amount of recoveries collected.
• Documenting dependent status for an array of family circumstances (student, adult dependents, divorces, adoptions, guardianship, etc.)

“The sophistication of Health Decisions’ recovery investigation carries over into recovery pursuit and collection,” adds Nahra. “All earlier facts and data are carried forward to support the wide array of collection techniques used by us. While we do not collect from individuals, we do pursue all other collection avenues including coordination with other payors, provider offsets, provider repayment, Medicare repayment, settlement negotiations, and enforcement of judicial orders.”

Most claim recovery firms do not get involved in enrollment verification. “We are the only ones doing enrollment reconciliation in the payor market,” says Nahra, “and in the employer market there are very few, if any, who come close to doing as comprehensive an enrollment reconciliation as we do with comparable results.”

In business since 1985, Health Decisions is the most experienced, independent, continuous health claims recovery and post payment administration firm in existence in the United States. “We offer a total solution, not just a recovery initiative,” adds Nahra, “and enrollment verification is a key tool used as we seek total solutions for all our clients.”

Contact Si Nahra to have Health Decisions provide your company with the tools to effectively administer your Health Care Plans today! Si@healthdecisions.com