Approved Provider Network

 

Approved Provider Network (APN)

Over the past fifteen years, Orion Audit has provided benefit audit services to a large number of plan sponsors, varying in size from 500 to 50,000 employees.

In recent years, Orion has identified significant irregular claims and fraudulent claims activity associated with medical equipment claims, costing plan sponsors millions of dollars. Currently, there are thousands of providers in the Canadian market supplying medical equipment to benefit plan members with extremely low or no barrier to entry within this market.

Over the past three years, Orion has developed a very useful and unique audit approach to help address this fraud. It not only involves an audit of claims and data analysis, but also integrates plan member and provider investigations on an arms-length basis, to avoid any conflict of interest.

This approach has been extremely successful in (temporarily) reducing fraud within benefit plans, and decreasing extended health costs as high as 40% for clients over an annualized basis. Having said that, it has been requested that stronger controls be implemented to mitigate the risk of benefits fraud on a long-term basis. This is the genesis of Orion’s Approved Provider Network (APN).

In response to this material fraud and plan leakage, Orion Audit has created an Approved Provider Network (APN) for specific medical equipment:

  • Compression Hose
  • Orthopaedic Shoes
  • Orthotics
  • TENS Machines
  • Braces

The focus of the APN is to introduce much needed accountability and controls for each of these medical equipment providers. Through key selection criteria, Orion will ensure the Approved Providers are reputable, qualified and will be staffed by credentialed practitioners.

Potential Providers have been thoroughly and fairly assessed through an application process. The primary goal of the application is to select a limited number of providers to supply medical equipment to the members of their respective benefit plans. Through this application process only Providers with sufficient qualifications are selected to participate in the APN.

Approved Providers must meet the following requirements:

  • Have qualified staff
  • Agree to facilitate periodic site visits and audits by an external audit company
  • Meet minimum business hour requirements
  • Cannot be delisted by any Insurer or Third-Party Administrator
  • Have locations that are accessible

Within the application process, Approved Providers are required to pass a site visit evaluation, and their respective proposals were further assessed based on pricing, return/exchange policies, and other general criteria.

Factors such as geographic location, language, and accessibility barriers were considered in selecting the Approved Providers, so as to ensure that employees and their dependents can still access the medical equipment they may need.

At the conclusion of this process, in order for claims to be considered for reimbursement through the benefits plan, employees and their dependents will have to purchase the specified medical supplies through the suppliers in the APN. Items not purchased from an Approved Provider will not be reimbursed through the benefits plan.