Audit & Claim Review

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GBS Auditing Services

Claim review and auditing is a critical program in the package of GBS services. Claims are the largest part of a health care purchaser’s health insurance costs.

A review of claims by an independent party results in greater accuracy and appropriateness.

To put the client in control and to maximize savings, GBS identifies Insurance Carrier/TPA/HMO billing and payment errors and, thereby assists the client in purchasing more economically.

With our technical expertise, insurance knowledge and sophisticated computer system, we deliver useful data for decision-making.

Group Benefits Strategies | Procedures

Carrier Administration Audit & Payment Analysis

Group Benefits Strategies staff checks the administration and reinsurance calculations to assure the proper charge is being applied. In addition, our enrollment database is cross-referenced to determine if charges have been applied for ineligible persons. Coordination of Benefits with Medicare is an area of potential savings. Although federal law prohibits the employer from placing actively employed persons or their spouses on a plan in which Medicare is the primary payer, there are circumstances in which coordination is permitted.

Group Benefits Strategies’ claim review staff will ensure that Medicare pays the liability wherever appropriate.

Duplicate and Other Disputed Claims

GBS also examines the claim administrator’s claim payment records each month to determine if a claim was paid twice, or if claims, which were improperly documented, have been paid.

Upon identifying these potential errors GBS completes disputed claims forms and submits them to our client’s claims administrator for review. GBS will monitor your monthly claims for any credits issued as a result of these disputed claims.

A GBS staff member reviews detailed claims once a member has reached 50% of the reinsurance deductible and audits for potential continuous admissions, erroneous dependent coding, and other discrepancies. If necessary, a Patient Authorization is obtained to request any needed data directly from the hospital or doctor.

Ineligible Claimants

Group Benefits Strategies reviews our client’s monthly claims payments against member eligibility files to determine if claims have been paid on behalf of persons who have been terminated, whose dependent status has changed, who were never a member of the client’s group, or who are utilizing someone else’s identification card.

The GBS system produces an exception report of each month’s claims payment records versus our client’s membership files.

When an exception is noted, the eligibility status is reviewed for the potential of recovery, and a “disputed claim” is filed with the claims administrator.

Credit Toward Stop Loss Reinsurance

Vital to the efficient administration of a self-funded, reinsured program is the effective tracking of claims accumulations. This tracking determines the subsequent reimbursement of claims, which have exceeded the Stop Loss Reinsurance attachment point.

Without an aggressive auditing program, the employer/purchaser may not receive credit or reimbursement due under the client’s reinsurance policy.

GBS prepares excess claims packages for submission to the reinsurer. These packages are prepared and submitted on an ongoing basis. The GBS staff members tracks reimbursement checks and reconciles them to the outstanding reimbursement amounts.


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