Process

BenefitsWatch usually begins with a retrospective audit to establish a baseline. The retrospective audit includes HDM's five-step protocol for analyzing 100 percent of claims. HDM's 100-percent-of-claims audit methodology was proven superior to random-sample audits in an independent study. You can download the study white paper here.

Data Warehouse
HDM requests your Third Party Administrator’s and/or your Pharmacy Benefits Manager’s database of claims and your eligibility and benefits data, and integrates all of this data into a centralized standard data warehouse. After the restropsective audit is completed, new data feeds occur monthly for continuous monitoring of administrator and PBM compliance.

There is very little for you to do at this point, but initially request the release of the data from your administrator(s) to HDM…a simple procedure, since we have worked with most of the major TPAs and PBMs in America, and maintain excellent relationships with them.

Business Rules Engine
HDM integrates comparative logic created from each Administrative Service Agreement (ASO), Summary Plan Description (SPD), formulary, industry standards, and HDM’s proprietary business rules.

Exception Analysis
Like BenefitsAudit, BenefitsWatch does not rely on a sample of data provided by administrators. The service addresses 100% of claims and eligibility data and compares and analyzes this data against best business practices and administrator's procedures. Exception reports are generated with potential errors and issues identified quarter-to-quarter.

Claims Audit
HDM analyzes 100% of claims according to the Administrative Service Agreement (ASO), Summary Plan Description (SPD) and industry standards, and performs an onsite claims audit to validate findings.

Discount Audit
HDM determines the discount arrangement that customers are entitled to through contracts with administrator(s) and verifies fulfillment of contract requirements by the administrator(s).

Financial Reconciliation
HDM performs 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, business process and operational review and financial reconciliation, HDM assesses contract compliance with emphasis on Summary Plan Description (SPD) description, reporting and contracted services. HDM then recommends contract changes based on best practices derived from our wealth of experience.

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

Clinical Analytics from a Financial Perspective
This is where it really gets interesting! We then apply additional software that provides a unique financial perspective on clinical data. It is this software that allows HDM to provide continuous monitoring of the other two critical areas of plan performance – Financial Management and Cost and Utilization. We do this on a rolling, quarter-to-quarter basis for the duration of the BenefitsWatch contract.

Audit Reports
HDM documents audit findings, administrator responses, and recommendations for improvements and cost-savings and issues reports every quarter like clockwork.

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.