Dental Plan Audits

Many self-insured employers do not think about their dental plans until they suspect problems. Verifying correct usage of dental plans is difficult because of out-date systems, misuse by participants, incorrect administration, and wrongful use of the dental plan due to lack of information or understanding.

Self-insured employers need assurance that plan administrators are paying dental claims accurately and according to plan design and the terms of the Administrative Service Only (ASO) agreement.

To achieve this goal, HDM conducts a comprehensive review of plan administration, including paid claims and provider discounts. Our proven process is aimed at determining the following…

• Compliance with both contract terms and plan documents.
• The financial accuracy of paid claims and administrative processes, including error and fraud detection.
• The accuracy of payments and identify overpayments.
• Identifing control weaknesses, their causes and suggestions on process enhancement/cost savings prospects.
• Assessing retail and mail order programs.
• Reviewing our client's role regarding administration and offering recommendations.
• Identifing, validating, and recovering overpayments.

The following services can be included in a dental plan audit:

Claims Audit
HDM analyzes 100% of dental claims versus the contract, summary plan document 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 administrators and verifies fulfillment of contract requirements by the administrator.

Business Process & Operational Review
HDM conducts an onsite operational review at the administrator's facility 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
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 will assess contract compliance with emphasis on summary plan description, reporting and contracted services. HDM will recommend contract changes based on best practices derived from our revered industry benchmarks.

Recovery of Overpayments
HDM presents validated claim errors and overpayments to the administrator for recovery. We also negotiate and monitor recovery collection activity to ensure that recovered dollars go to our client.

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.