Problems we solve through auditing

 

Claims

The cost of health care benefits is among the largest expense items for most employers. Plan sponsors put a lot of effort into designing health care benefits for their employees and need to be assured that these benefits are being provided at the right cost. Typically, this assurance comes from an independent audit of their third-party claims administrator.

My health care costs are continuing to rise

Electronic claims payment systems minimize errors, but the complete claims payment process relies on human judgment. Weak investigative efforts, volume pressures, poor claims payment systems, outdated software, internal policies and human interpretation are just some of the factors that can attribute to claims payment issues.

I'm unsure if my claims are being paid appropriately

Independent third-party testing of claims adjudication procedures can provide peace of mind and/or prevent costly future mistakes. Claims audits uncover a wide variety of claims adjudication issues and/or weaknesses such as system limitations, plan-build inaccuracies, overuse of processor overrides, and provider billing errors.

I'm aware of a problem, but do not know if it was corrected

Trust, but verify. Third-party administrators often pay for a claims audit to restore customer confidence. A comprehensive analysis of claims can help determine whether or not an issue could be systemic or isolated.

I'm facing increased scrutiny to demonstrate fiduciary responsibility over the plan

Sponsors of health plans have a fiduciary obligation to participants and/or shareholders to confirm plan resources are being used correctly. Failure to uphold fiduciary duties can result in legal penalties for the Plan Administrator including personal financial liability.


Dependent Eligibility

With increasing forms of self-service online enrollment, lax eligibility vendor controls, and some plans even excluding spouses from dependent eligibility for coverage, the number of ineligible dependents for any given organization can range between 2-10%.

My health care costs are continuing to rise

Few forms of health care cost containment activities provide such immediate savings. Given the fact that the average dependent can cost an employer a minimum of $3,000 annually, it’s not uncommon for an employer to achieve returns on investment ranging from 100% to over 5,000%.

I found out we were covering an ineligible dependent, but am unsure if there are more

Employers can reduce their stop-loss denial risk by ensuring only eligible dependents are enrolled.

I can't tell if I have ineligible dependents on the plan

A thorough review of each dependent’s eligibility and supporting documentation can provide piece of mind or uncover dependents who should have never been enrolled. A dependent eligibility audit can also help the entire organization understand more about their own eligibility requirements.

I'm facing increased scrutiny to demonstrate fiduciary responsibility over the plan

Sponsors of health plans have a fiduciary obligation to participants and/or shareholders to confirm plan resources are being used correctly. Failure to uphold fiduciary duties can result in legal penalties for the Plan Administrator including personal financial liability.

We lack internal resources to conduct an audit ourselves and question if it can be outsourced

Many organizations don’t realize that conducting a dependent eligibility audit internally is a significant undertaking. Hiring an outside vendor provides a buffer between human resources personnel and employees to ensure objectivity while also minimizing conflict.