By the Numbers: Eligibility Audits

Written by Book Chrobak, Health Analytics Manager


Many of us read about the importance of the plan document language in last month’s By the Numbers.  Eligibility is an important part of a strong plan document and is the topic of our CSI bulletin this month.  Employers are the main source for health benefits for people in the United States, with approximately 151 million people on an employer plan.  Performing an eligibility audit can maintain plan integrity and provide savings to the employer.

Research shows that anywhere between 2 and 10% of plan participants are not eligible per the guidelines outlined in the group’s summary plan document.  Ineligibility can be for a variety of reasons and not solely because of deception by the participant.  Most often a plan participant is an aged out dependent or an ex-spouse/non-domestic partner.  Performing an eligibility audit can identify those dependents who are not eligible.  Let’s review the numbers in an example to see potential savings from an eligibility audit.

The average dependent claim payout is $4,700. If an audit discovered 3% of the 100 dependents on the employer group health plan are not eligible, the claims payout savings calculates to $14,100.  Additional savings are realized through reduced premiums and lower administration costs.  This simple example illustrates how an eligibility audit maintains plan integrity and provides savings to the employer.  Roundstone provides eligibility verification for all plan participants once the individual reaches the stop loss level.

 

About Book Chrobak: Book is currently a Health Analytics Manager at Roundstone. In the Health Analytics Manager role, Book helps with all things related to data: creating reports and visuals, participating in our CSI (Cost Savings Investigators) Team, and researching new data tools to attract and retain clients. He graduated with a major in Mathematics from the College of Wooster and completed his M.B.A. with a Finance concentration at Cleveland State University. Book has held data and IT roles at financial and insurance software companies prior to joining Roundstone.

Book currently serves on the College of Wooster Alumni Board, participating on the Alumni Engagement and Distinguished Alumni committees.  He is a proud Cleveland, Ohio resident living in the rising Old Brooklyn neighborhood.  He serves on multiple committees for the Old Brooklyn Community Development Corporation Board. Book served six years on the Old Brooklyn Community Development Corporation Board, with a final year as Board President. Book enjoys running and has completed the Cleveland, Columbus, Marine Corp Marathon, and Chicago marathons. He has also run two 24 hour ultra-marathon races, achieving 100 miles in one of those races.