Process

Implementation
Implementation takes very little of your time. You are assigned a Project Manager and Account Manager who handle virtually everything for you. We have worked with most of the major administrators and PBMs in America, and maintain excellent relationships with them.

Five-Step, 100-percent-of-Claims Protocol

Data Warehouse
HDM downloads all of the data from steps 1 and 2 to a centralized standard data warehouse.

Step 1: HDM requests paid claims data from your Third Party Administrator (TPA) and/or Pharmacy Benefits Manager (PBM).

Step 2: You provide HDM with eligibility data, benefits covered and not covered, place of service, co-pays, etc. – the Summary Plan Description (SPD). and your administrator’s business rules – the Administrative Service Only (ASO) Agreement.

Benchmarks
Step 3: HDM integrates comparative logic created from each ASO, SPD, formulary, industry standards (e.g. CMS, AMA, FDA rules, etc.) and HDM's proprietary logic designed to seek out duplicates and fraud.

Exception Analysis
Step 4: BenefitsAudit does not rely on the random-sample methodology. Our service addresses 100% of claims and eligibility data for the audit period. We compare and analyze this data against best business practices and administrator's procedures. Exception reports are generated with potential errors and issues identified.

Claims Audit
Step 5. After analyzing 100% of claims according to the ASO, SPD and industry standards, HDM performs a sample onsite claims audit to validate the logic and findings of the 100% analysis.

In addition to applying our 100-percent of claims protocol, we also perform a discount audit, business process and operational review and a financial reconciliation.

Discount Audit
HDM determines the administrator discounts that our client is entitled to by scrutinizing contracts with administrators. We also verify fulfillment of contract requirements by the administrator.

Operations & Business Process Review
We also conduct an onsite operational review at the administrator's facilities to evaluate the control environment and assess the risk of fraud or error. We review internal control policies and procedures, and determine if errors or irregularities have occurred or the likelihood of them occurring.

Financial Reconciliation
We perform a financial and funding reconciliation, utilizing administrator reports and customer banking records. We review adequacy of the funding requests, and reconcile all funding and payment banking records, thus assuring there are adequate controls over financial transactions.

Contract Compliance Audit
As a result of performing a claims audit, discount audit, and operations and business process review and financial reconciliation, HDM assesses contract compliance with emphasis on SPD description, reporting and contracted services. We then recommend contract changes based on best practices derived and our extensive experience.

Recovery of Overpayments
HDM presents validated claim errors and overpayments to the administrator for recovery, and negotiates and monitors recovery collection activity to ensure that recovered dollars go to our client.

Audit Reports
HDM documents audit findings, administrator responses, recommendations for improvements and cost-savings in a single, final report.

To discuss how HDM’s cost containment solutions for self-insured employers can benefit your organization, contact HDM today at 800.859.5119 ext. 1 or e-mail your inquiry to: info@HDMinc.com.