Employee benefits

Eliminating fraud, waste and abuse in employee healthcare claims adds value without disruption

By: Vispi Jilla, SmartLight Analytics Principal Advisor 

Healthcare and benefits are tools companies use to gain a competitive advantage to attract and retain talent. Both are used in the recruiting process to attract high performing employees. The question is how do you continue to offer competitive benefits to attract and retain talent while costs for healthcare, in particular, continue to rise?  

Businesses focus on profits and cost savings. So, reducing the cost of healthcare benefits for self-funded employers is paramount. It is important to provide the best coverage to attract and retain the top talent, but without jeopardizing company profits. SmartLight has the tools — not just the analytics but the medical expertise — to find fraud, waste and inefficiencies existing in employers’ healthcare spending. Identifying, remediating, and eliminating these costs will allow employers to find those savings needed to limit excess health costs and continue providing quality healthcare coverage to employees.  

How are savings realized? When it comes to reviewing claims data, what many do not understand is that statistical models and algorithms are not the only required tool to find payment errors in healthcare claims. Experience and expertise is also are instrumental to detecting outlier patterns and anomalies in claims. Many companies rely on analytic know-how but do not have the expertise in house to review claims at this deep level. SmartLight combines data analysis and the clinical expertise to provide a new and significantly increased level of review. This depth results in greater savings.  

In most companies, executives rely on “runs” from payers, say BCBS for example, to explain the expenses going into employee healthcare claims. Most often, HR pays the expense without much review. Seldom is anything ever done to investigate the healthcare claims because the numbers are so opaque and the expertise is not there to analyze claims. Businesses classify the expense as “healthcare inflation” and just keep passing the increase on to employees in the form of higher premiums or co-pays or deductibles. The rising costs of healthcare can also eat into profits. 

Partnering with SmartLight Analytics’ team of experts provides is on average a 4X ROI. If you are a self-funded employer with $100 million in healthcare costs, saving $3-5 million from fraud, waste and abuse will allow you to pass that savings (instead of expense) on to your stakeholders in the form of profits, and to employees through possible reductions in premiums. Working to reduce these inefficiencies in healthcare claims can also help improve the quality of employee care. When done correctly, it is a win-win. 

HR is tasked with so many processes in today’s corporate world; these executives need an independent advocate with the necessary expertise to find and reduce the rising healthcare costs in their sponsored healthcare plans. Unlike an expense like purchasing steel or trucks where you can simply shop around for cost saving options, it is not easy to change healthcare providers. It can cause considerable employee dissatisfaction when changing insurance carriers.  The better option is to make your existing healthcare provider more efficient and eliminate fraud, waste, and abuse in the claims, it adds value without disruption. Then HR can focus on other things instead of spending finite resources on deciphering healthcare costs.