03/27/2008
You are a valuable partner for External Audit
As you may know, Asuris has a comprehensive External Audit and Investigation department whose mission is to identify inappropriate and abusive billing patterns involving both providers and members. Among its responsibilities is ensuring appropriate group and member eligibility.
In many cases, brokers and agents are on the front line in preventing enrollment of ineligible individuals and groups. A few things you can do to help:
- Make sure all enrollment paperwork is accurate and complete and that it reflects the terms of the understanding between the group or individual and Asuris. In the case of Individual applicants, brief them on the importance of noting any and all conditions on the Health Questionnaire.
- Brief the group administrator on his or her responsibility to monitor employees' hours worked in order to maintain eligibility.
- Educate the group administrator regarding eligibility requirements and COBRA, if appropriate. See Article 2 of the health care contract or visit our Web site for specific rules. You should always consult the contract to ensure compliance.
Although brokers and agents, like Asuris, work in a trust-based environment, we encourage you as representatives of Asuris to practice due diligence in order to determine appropriate eligibility of your group and Individual clients. Eligibility fraud and falsification of health care declarations have the potential to increase utilization, and increased claims experience often results in higher rates for groups and subscribers.
Please feel free to contact Susan Paine at (253) 382-7759, for further information or for help in identifying those who may or may not be eligible for coverage. If you have other questions, please talk to your Asuris Sales contact.
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