Provisions of the Affordable Care Act (ACA) continue to drive health care cost increases for organizations. According to the International Foundation survey 2016 Employer-Sponsored Health Care: ACA’s Impact, respondents anticipate an average cost increase of 5.8% in the current year. These increased costs are motivating employers to conduct new audits and analyses of internal health care data. In addition to verifying plan accuracy, these audits investigate procedures, operations and records to ensure that care practices meet with predetermined criteria.

Dependent Audits

Most commonly, one-quarter of surveyed organizations (24.9%) have conducted dependent eligibility audits or plan to do so in the next 12 months as a result of the ACA (14.3% and 10.6%, respectively). These audits are conducted to verify whether spouses, domestic partners and/or minor children meet the specific criteria for receiving health care coverage from the organization.

Dependent eligibility audits are often driven by divorces or separations of plan participants. After separation, ex-spouses continue to be covered by the plan despite loss of eligibility. In addition, it is assumed that some of these audits were driven by the ACA rules regarding the dependent coverage of children. As of 2014, both grandfathered and nongrandfathered plans must offer to cover a participant’s adult children up to the age of 26, regardless of whether the child has his or her own coverage through a job or spouse.

[Related: The Effects of ACA on Medical Expense Accounts (HSAs, FSAs and HRAs)]

Claims Utilization Analysis

There has also been a noticeable increase in health care claims utilization analysis, as 23.7% of survey respondents have conducted or plan to conduct this analysis in the next 12 months (13.8% and 9.9% respectively). Claims utilization analysis reviews the extent to which a group uses particular services during a particular year. The goal of this technique is to control costs while eliminating the overuse and underuse of health care services.

In addition, 18.2% of respondents are conducting or plan on conducting health care claims audits in the next 12 months (9.9%, and 8.3%, respectively). These audits more specifically examine a health provider’s records to assess whether services were necessary, properly administered and correctly billed.

2016 Employer-Sponsored Health Care: ACA’s Impact is the seventh survey in a series on how corporate health benefit plans are being affected by the Affordable Care Act. Survey responses were received from human resources and benefits professionals representing a wide base of U.S. employers from nearly 20 different industries and ranging in size from fewer than 50 to more than 10,000 employees.

Justin Held, CEBS
Educational Program Specialist/Research Analyst at the International Foundation