When ELAP audits or reprices a claim, our goal is straightforward — to recognize the medical provider’s actual cost to deliver the service and to allow a fair margin above that cost. To accomplish that goal ELAP utilizes various sources with a particular focus on Medicare and the annual cost reports many medical providers submit to the Centers for Medicare & Medicaid Services (CMS). Always, we seek to move away from billed charges towards a reimbursement strategy based on transparency and cost-based metrics.
The Audit Program has three key components
- Plan language that contains clearly stated and rational limits of reimbursement
- An appeal process that provides a full and fair review of any appealed claims
- A vigorous defense of the plan and plan member in the event of a balance bill or collection action
The ELAP Audit Program assists a plan sponsor in performing their fiduciary duty under ERISA to prudently disburse plan assets. The result is reduced cost and a process that balances the rights of medical providers for fair reimbursement with those of the plan sponsors and plan members that pay for care.