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Payment Integrity Solution

Helping you reduce (and reverse) wasteful health care spending.

Benefitfocus’ Claims Audit & Recovery Services will analyze your medical claims to identify potential payment errors and work with providers to recover the funds on your behalf.  

The Challenge

Health plans are facing a triple threat today. 

Rising health care costs

Annual U.S. health care spending hit $4.3 trillion in 2021, which averages to nearly $13,000 per person.1 

Improper payments

The CMS Payment Error Rate Measurement Program has reported claim payment error rates of up to 21% over the past three years .2 

ERISA considerations

Employers functioning as plan fiduciaries are responsible for ensuring that plan assets are protected against fraud, waste and abuse.3

How our solution is different

We’ll complement and augment existing claim review processes to help recover improperly paid amounts for you – at no risk to you and with minimal effort required from you.

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  • Comprehensive review: While other payment integrity solutions may draw conclusions from a small data set, we review every medical claim the employer health plan has paid. 

  • Opportunity for successful recovery5: As an example, for one client, our process found an $80,000 error within just one claim – the result of multiple duplicate payments. 

  • Money back to members: In addition to identifying plan overpayments, we’ll also identify member overpayments to help put money back in the pockets of your employees and their families. 

  • Independent and unbiased: The sole focus of our payment integrity solution is working on behalf of employer health plans and their members. 

  • No fee to get started:  There is no fee to activate this service for Benefitfocus clients with Health Insights. Benefitfocus only collects a portion of recovered amounts.4 

  • Continual improvement: Proprietary processes are constantly being refined to catch mistakes with greater accuracy. 

integrity payment solution

Payment Integrity Solution Overview

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How it works

Health care costs too much as it is. Our payment integrity solution targets health care dollars that should never have been spent in the first place. Here’s what we’ll do on an ongoing basis: 

Integrated via Health Insights analytics platform.

Five key areas reviewed to flag improper payments.

Sent to provider with details and instructions to remit repayment.

Provider remits repayment to client lockbox and, if applicable, directly to members.

Quarterly disbursement to client along with reporting.

Featured Content

Take a test drive

Schedule a consultation with a member of our team to learn more about our payment integrity solution!

1Peter F. Peterson Foundation, “Why Are Americans Paying More for Healthcare?,” 2023, 2Centers for Medicare and Medicaid Services, “PERM Error Rate Findings and Reports,” 2023, and 3U.S. Department of Labor, “Fiduciary Responsibilities.”  

4 Claims Audit and Recovery is no fee to activate for Benefitfocus clients with Health Insights. Service dependent on cooperation with carrier/TPA. Benefitfocus will take only a percentage of recovered amounts . As part of implementation, customers may need to provide additional documentation and sign an agreement to authorize review and recovery of claims.  

5Actual recovered amounts vary among customers.