Eligibility audit presentation current
- 2. Newer Alternatives for Lowering Health Care Costs Fully Insured and/or Self Funded Plans 2
- 3. OBJECTIVE To insure that employees who claim dependents on the employer-sponsored health plan are truly eligible dependents based on the definition of a dependent as outlined in the Plan Document 3
- 4. Presentation Overview The stages to a Dependent Eligibility Audit are: 1. Planning 2. Common Objections 3. Communication 4. Documentation 5. Data Accumulation 6. Results/Findings 4
- 5. Presentation Overview (cont’d) 1. Planning • Audit Format • Overall Project Goals and Objectives • Timeline: ideal prior to open enrollment 5
- 6. Presentation Overview (cont’d) 2. Common Objections • Trust issues from employees as this is a delicate undertaking • Initial reaction to cost of the project • Sensitivity in a union environment 6
- 7. Presentation Overview (cont’d) 3. Communication is KEY • Amnesty Phase – no disciplinary action • Structure of communication to fit corporate culture • Additional phases as applicable 7
- 8. Presentation Overview (cont’d) 4. Documentation Gathering & Authentification • Burden is on the employee to prove that a covered dependent is actually entitled to coverage - That usually means providing documentation such as copies of marriage certificates, birth certificates, adoption agreements, income tax returns and letters from colleges. • Type of documentation, FAQ’s, examples • Onsite authentication vs. documents mailed, faxed, or e-mailed 8
- 9. Presentation Overview (cont’d) 5. Data Accumulation • Call Center or an experienced live team available to answer employee questions regarding the audit, acceptable documents, etc. • Tabulate responses from employees’ and maintain in a database • Analyze responses and provide summary of findings 9
- 10. Presentation Overview (cont’d) 6. Results • Cost benefits to employer – Reduce health care costs – Lower future administrative costs – Lower Premiums – Lower cost for employee share with savings 10
- 11. Business Impact • ERISA Fiduciary Compliance • Return on Investment • Without a process in place to protect an employer’s health plans, covering ineligible dependents will continue to put the organization at risk • Employees who cover ineligible dependents not only increase the cost for the employer and fellow employees, but also contribute to eroding an organization’s ethical standards. 11
- 12. Business Impact (cont’d) Options for measuring ROI • Calculate future reinsurance premiums and/or administrative costs on a go-forward basis • Calculate actual or expected claims paid for ineligible dependents • Seek restitution from employees for ineligible dependent(s)’ claims previously paid, or for premiums and administrative fees 12
- 13. Business Impact (cont’d) ERISA Fiduciary Compliance • Plan sponsors have a fiduciary responsibility to minimize risk to the health plans • Plan sponsors’ failure to protect the health plans from exposure caused by covering ineligible dependents is a violation of the fiduciary responsibility as defined by ERISA. 13
- 14. QUESTIONS & ANSWERS For more information, call: Phyllis Hoff (314) 692-5887 14