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Contain costs and maintain health plan compliance through regular auditing

As healthcare costs continue to rise, it’s important that you’re actively managing your benefit plans to ensure they’re meeting the needs of your members, achieving optimal outcomes, and adhering to your plan guidelines.

Do you know how your benefit plans are performing?

 


Don’t neglect the importance of regular plan audits

Many companies assume their plans are working as intended, but if your organization only addresses vendor performance after a problem becomes known, you may be missing costly errors. Regular audits are also critical for promoting vendor accountability and preventing regulatory infractions.

As an independent consultant with specialized healthcare knowledge, we’re equipped to conduct a variety of medical and prescription drug-related audit services, as well as other specialty audits. Our rigorous audit process and propriety technology digs deep into your data to provide meaningful insight about the performance of your plan and uncover issues before they become bigger problems.

We strive to provide a positive audit experience for all parties, earning high marks from our clients for customer service and ranking as a best-in-class provider by major insurance carriers, and can help you:

  • Navigate the complexities of conducting an audit
  • Develop a custom audit strategy that meets specific concerns
  • Evaluate the results and implement a correct action plan as needed
  • Satisfy fiduciary responsibilities
  • Monitor vendor performance

Our healthcare audit solutions

Medical claim audits

We offer two audit strategies to review medical claims:

  • Our stratified, random sample audit methodology takes a broad look across multiple claim types, helping to ensure plan compliance and identify payment errors as well as measure processing, payment, and procedural accuracy which can be used to validate self-reported performance guarantees.
  • Our targeted audit methodology takes a deep dive into the claim data and can be customized to address your specific concerns. A targeted sample is selected, focusing in on potential “at-risk” areas within a plan.

Prescription drug claim audits

Even minor issues can be costly. Our comprehensive, 100% electronic prescription drug claim review identifies areas of risk and analyzes contractual financial guarantees and other program materials to ensure that your Pharmacy Benefit Manager (PBM) is administering the plan in accordance with your expectations. We specialize in navigating the complexity of prescription drug benefits services to ensure accurate payment of Rx benefits, and recover funds lost from overpayment.

Manufacturer rebate audit

Manufacturer rebates are a part of every pricing arrangement for PBM services. The only way to know whether the terms of the PBMs manufacturer contract are being administered correctly is to conduct a manufacturer rebate audit. As an approved rebate auditor for all major national PBMs, our team is highly skilled at reviewing and auditing both manufacturer contracts and PBM agreements to ensure that you are getting the rebates you are entitled to under your specific arrangement.

Other healthcare audit opportunities

Regular audits are an important step for holding all your health care vendors accountable. Our team is well versed in a variety of specialty plan audits, including dental claim audits, carve-out plan audits such as behavioral health, vision, hearing, physical therapy, and life insurance audits.

Do you know who is covered on your health plan?

In addition to our healthcare audits, our dependent eligibility verification process ensures that dependents enrolled on your plan are eligible for the plan. Our team is compassionate and takes the time to understand your data and your organization’s culture to make sure the process is consistent and ineligible dependents are directed to appropriate alternatives for coverage.

Contact us today