Everything is about to change. We are bringing the most advanced proactive analytics - artificial intelligence, machine learning, and behavioral profiling - to bring transparency, accountability and control to the way self-insured employers manage and monitor their health benefits.Here's how...
Today, employers who rely on third-party administrators often have very little visibility into how their benefits programs are managed. Healthcare is the only industry where the client (patient) has no idea what they (in most cases their providers and employers) are paying for. Unclear invoices are issued and blind checks are written with no accountability. It’s a problem that is compounded by the size and complexity of health benefit programs, the law, and the sophisticated tactics of criminals.
We provide organizations a new level of information about their programs and visibility into what is being paid and what should not be. Because we are fully HIPAA compliant, we can drill deep into the data to spot trends across providers, employees, and payers, and compare current activity with historical trends to spot anomalies and opportunities. We also bring de-identified data from other employers in the same geography, giving us the ability to not only spot improper payments, but provide opportunities to reduce costs and improve the quality of care.
For years, policymakers and employers have tried to reign in the growth in healthcare spending. It hasn’t worked. It is a problem due in no small part to our nation’s inability to get a handle on $300 billion of waste and fraud every year.
So why have we been losing the fight against fraud? In simple terms, administrators are finding it too late, if they find it at all. Today, most payers conduct audits for improper payments after claims are paid, and then “pay and chase” to recover it. This “ask questions later” approach works less than 5% of the time.
At 4C, we are charting a new course. Our first-of-its-kind platform scans across medical, dental and other claims in real time to find fraud before claims are paid. This eliminates the cost of 100% of identified fraud and waste, without delaying payments of legitimate claims.
Under the Employee Retirement Income Security Act of 1974 (ERISA), corporate fiduciaries are required to take the steps necessary to protect the assets of employee health benefit plans. If they fail to, they may be held personally liable for improper payments, fined up to $100,000 , and sentenced to up to ten years in prison.
Recently, several class action suits – where plaintiffs are seeking hundreds of millions of dollars in damages – have been filed against employers, administrators and individual fiduciaries.
By putting in place the industry’s best safeguards to defend – not just recover – fraud and waste, we allow fiduciaries and companies to meet their responsibilities under ERISA and avoid legal risk, including class action suits and government prosecution.
Given the complexity of health benefits today, it is no wonder that organizations turn the management of these programs over to third party experts. But it comes with a steep cost. Companies are relinquishing control over one of the largest and fastest growing expenses on their balance sheets.
To make matters worse, too often the incentives for TPAs are often misaligned with the needs of employers. This is because TPAs are generally compensated per member per month or based on the number of transactions they process. They also require additional fees to audit paid claims to identify fraud. This emphasizes paying claims over finding fraud, and recovery over prevention.
It doesn’t need to be this way. By providing employers with independent visibility into their health benefit programs, we enhance accountability, protect all parties, and put control back into the hands of the party with the most at stake. We also provide employers with data to help them identify the most efficient providers who offer the highest quality care.