Medical & Rx Claims Review
Employers faced a 4.5% increase in their healthcare budgets in 2023 versus 2022. In 2024, projected average costs for U.S. employers that pay for their employees' health care could increase 8.5% to more than $15,000 per employee.*
Hospital bills and retail specialty and non-specialty pharmacy drugs are the primary drivers of the excess burden cost to plan sponsors. The primary reason for overpayment on medical and prescription claim benefits is attributed to errors in billing and coding. Overpayment also occurs due to changes in pricing agreements, contract discrepancies, or outdated fee schedules. Insufficient coordination between healthcare providers and insurance plans can contribute to billing inaccuracies, leading to overpayments.
With Amwins’ expertise in audits, brokers can focus on retaining and winning new business while we help their plan sponsors identify areas of unnecessary spending, negotiate better rates with healthcare providers, and ultimately optimize the financial performance of the health benefit plans.
Your Challenge
Our experts review the entire claim process from patient to provider to insurance carrier. When we’re done, you will have an effective action plan that eliminates waste and adds value to your bottom line, potentially recovering historical money owed. Our review services examine the major contractual elements which provides a clear view of how well contract terms have been implemented. The client will understand contract term failures and financial impacts. You win because we are significantly different from the major audit firms.
Our Solution
Our Medical and Rx Audit Solution is one of the most comprehensive tools to assist your plan sponsors mitigate risk as well as delivering financial savings.
Our review processes include:
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Mechanical Duplicates Review
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Procedural Coding Inconsistency Review
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Clinical Irregularity Review
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Assistant Surgeon Overpayment
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Medical Rate Consistency Review
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Paid-In-Excess-Of-Charged Review
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Pricing, Dispensing Fees, and Rebates
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Scripts Filled Too Soon
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Unsupported Therapy
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Maximum Daily Dosing
Audits should be part of your annual cost-containment strategy.
Why Choose Us?
Our experts review the entire claim process from patient to provider to insurance carrier. When we’re done, you will have an effective action plan that eliminates waste and adds value to your bottom line, potentially recovering historical money owed.
Our review services examine the major contractual elements which provides a clear view of how well contract terms have been implemented. The client will understand contract term failures and financial impacts. You win because we are significantly different from the major audit firms.
Key Differentiators of our Medical & Rx Claims Review
Our Medical and Rx Audit Solution is one of the most comprehensive tools to assist your plan sponsors mitigate risk as well as delivering financial savings.
Our review processes include:
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Begin with contractual consultation to explain the audit rights
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Built-in rules engine for almost 2 million billing codes comparison.
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100% review of claims, everyone else does a sampling approach
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96% of our review results in actionable insights.
Let our audit experts handle the process from start to finish, letting you maintain focus on your core competencies while achieving the overall best results - with no delays, no mistakes, no surprises, and no hassles.
Leverage Our Expertise Today!
Transform your benefits strategy. Empower your clients. Amplify your results. Discover tailored solutions for Brokers and TPAs in the self-funded arena.
Amwins Health & Employee Benefits Consulting has the solutions to help you gain and retain clients.
