CCAR ™

The purpose of our Comprehensive Claims Audit and Reporting (CCAR) is to evaluate coding errors that are potential overpayments identified during the Assessment Period along with plan benefit processing errors and identify overspend form our unique anomaly analytics.

CCAR assists self-funded healthcare entities as follows:

• Assessing plan administrator errors in processing claims pursuant to their SPD
• Identifying their past medical claims overpayments due to miscoding
• Exposing anomalies in the Plan Sponsor’s medical spending that cause overpayments
• Reducing future overcharges by implementing changes related to our findings
• Assisting in recovery of those overpayments identified from our process

The analytics and audit report provides the following for proactive initiatives:

• Understand areas of concern to reduce cost
• Highlights gross overpayments by category and by procedure
• Compares clients high dollar medical procedure cost to LJB’s Cost Data Repository
• Identifies clients specific high dollar Cost Trend Analysis
• Examines and reports erratic cost trends thru data mining
• Empowers on-site audit with anomalies found in the data for on-site investigation
• Identifies Administrators (ASO) payment errors pursuant to the SPD
• Arms client for better negotiations at renewal
• Provides a complete explanation of the methodology utilized
• Provides a detailed description of the electronic parameters utilized to identify incorrectly coded claims
• Provides Recommendations, Summary, and Conclusion

CCAR is a three audit approach utilizing 100% of your prior 24 months paid claims.

There are three distinct services that our Claims Comprehensive Audit Reporting (CCAR) Audit provides in one combined service:

1. Plan Audit: This is an unique approach by analyzing 100% of paid claims (vs. the traditional 200-500 claims sample) through our ARMOR system. Then utilizing the data mining findings to incorporate more areas for investigation as input to the traditional plan compliance testing. The outcomes of the next two areas of audit analysis will be combined with the Benefit Plan testing outcomes. The unique comprehensive findings are utilized to build the sample utilized for the on-site audit validation and remediation phase of our approach.

   Key Benefits: Comprehensive approach to fix plan processing errors, overpayments due to miscoded claims, and spending issues not currently known

2. Correct Coding Analysis: ARMOR analyzes every paid claim against all related claims with over three million medical coding edits that are customized to the ASO’s Medical Payment Policy.

   This is additional and a different audit to the traditional plan audit that traditional audit companies provide.

   Key Benefits: Identify coding errors to be fixed by the administrator and generate perpetual future savings from overcharges to include possible refunds for systemic coding errors. These findings are included in the sample for the on-site audit validation and remediation phase.

3. Anomaly Analytics: This unique technology audit will expose anomalies (i.e. irregularities such as reduced occurrences of the same procedures during a range of time where the cost increased disproportionally) in the claims data that are not currently known or easily found that cause overspending.

   This is additional and a different audit to the traditional plan audit that traditional audit companies provide.

   Key Benefits: The on-site investigation phase of our process will address the issues ARMOR exposed from specific analysis to include data mining, specialty drug analysis, cost trend analysis, and cost comparisons to our LJB Cost Data Repository. These findings are included in the sample for the on-site audit validation and remediation phase.

The ROI from our process is higher than a traditional audit as the Correct Coding Analysis and Anomaly Analysis finds greater savings opportunities than the traditional standalone plan audit. Additionally, the traditional benefits audit only uses a small sample of clams Where the CCAR benefits audit component uses 100% of the claims to be analyzed.