Audit controls - reduce abuse

Passive Health Audit Strategies

Defined Contribution vs. Defined Benefit

Eliminate the need to scrutinize each claim by changing the focus to the claim total per member rather than components of the total.

Defined contribution medical and dental plans shift the responsibility of auditing charges for products and services to plan members.

Coinsurance

A coinsurance encourages members to shop for value and scrutinize the bill.

Manage Participation

distributing claim payments at work helps audit employee eligibility for benefits
employee contributions to the dependent premium for health and dental encourages those with spousal coverage to decline duplicate dependent coverage
employee contributions to the health and dental premiums encourages those with spousal coverage to decline duplicate coverage for themselves and their dependents
too much convenience, like direct electronic submission of claims, encourages ineligible spousal and dependent claims by employees who ignore the co-ordination of benefits provision

Assignment of Claims

The concern with assigned claims is that the patient no longer assesses the value of the benefits they use. Patients that pay for services and submit claims for reimbursement is keenly aware if the charge was $20 or $200. Direct submission of claims leaves little room for the patient to make cost benefit analysis. It also removes the patient from the role of reducing charges for services not provided. This places a greater burden on the adjudicator to prevent fraudulent claims.