U.S. Department of Labor (DOL) Employee Benefits Security Administration (EBSA) Medical Claims Analysis

Challenge: EBSA needed data analytics insights to support its case against a major health plan provider denying benefits for covered services.

The Department of Labor (DOL) Employee Security Benefits Administration (EBSA) safeguards private sector employee benefit plans. These benefit plans include employer-sponsored health plans that cover over 140 million Americans. Since 2015, Summit has served EBSA and supported dozens of regional and national investigations against health plan providers through sampling techniques and statistical analysis. 

Over the past five years, Summit has become a trusted advisor to EBSA to identify bad actors and help American taxpayers recoup millions in improper payments and wrongful denials. For example, EBSA investigated a major health plan provider accused of denying beneficiaries’ services their plans covered. These denials meant beneficiaries either paid out-of-pocket for covered health services or went without services all together. To make its case and estimate damages, EBSA enlisted Summit to analyze the provider’s health claims.

  EBSA Case Study: By the Numbers

  • For over 5 years, Summit has provided analytics oversights to EBSA, a federal department that safeguards employer-sponsored health plans covering over 140 million Americans.
  • Analyzed, sampled, and tested millions of health claims for validity and enforcement.
  • Created tools to empower EBSA investigators to independently analyze claims and secure damages.

Summit’s Solution: Summit identified a pattern of claim denials from the health plan provider and calculated $5 million in fees for denied services.

In this single investigation, Summit analyzed over one million health claims to determine the validity of the case against the provider and the extent of the violations. We completed a trend analysis to develop key research questions for the investigation, focusing on patterns in the rate of denials for beneficiary subgroups. The analysis identified violations over dimensions of time, volume, and value that indicated systemic issues in the provider’s claims adjudication process. We additionally analyzed the claims to calculate hidden management fees.

Over the course of our partnership with EBSA, we have provided support for dozens of similar investigations covering over 140 million Americans. In addition to the analyses Summit conducts on behalf of EBSA, we also create tools for investigators to independently manage their own investigations, including claims analysis and selecting samples of claims for review.

Result: EBSA now has the data it needs to support cases against the alleged health plan provider(s). Investigators are empowered by tools to manage and conduct investigations on their own.

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