Medical Plan Audits

Under our BenefitsAudit umbrella, many of the health plan audits we do focus on medical claims, the largest segment of a self-insured employer’s health plan cost.

Medical claims are often overpaid, paid for services that are not covered by your plan, or paid for patients who are no longer eligible for such coverage. Given this, the many factors escalating employee health plan costs today, and the Sarbanes-Oxley requirements that public corporations must adhere to, it is now more important than ever to assure compliance with your Administrative Service Only (ASO) and Summary Plan Description (SPD) in the area of medical claims.

HDM’s Medical Plan Audit retrospectively assesses the financial accuracy of paid claims and administrative processes – not just a random sample of claims, but 100 percent of claims, each scrutinized by HDM for scores of exceptions to your codified and modeled ASO and SPD.

Self-insured employers, who select HDM, get the assurance they need that plan administrators are consistently paying medical claims accurately and appropriately. HDM conducts a comprehensive review of plan administration and provider discounts, in addition to scrutinizing 100 percent of paid claims for the audit period. Our goals are to…

• Determine compliance with both contract terms and plan documents.
• Assess financial accuracy of paid claims and administrative processes, including claims error and fraud detection.
• Evaluate accuracy of payments and identify overpayments.
• Identify control weaknesses and their causes, and suggest process enhancement/cost savings prospects.
• Assess provider network penetration, utilization, and discounts.
• Review our client's role regarding administration and offer recommendations.
• Identify, validate, and recover overpayments.

The following services can be included in a BenefitsAudit medical plan audit:

Claims Audit
HDM analyzes 100% of medical claims according the contract, summary plan document and industry standards, then performs an onsite claims audit to validate findings. We also determine the discount arrangement that clients are entitled to through contracts with administrators and fulfillment verification of contract requirements by the administrator.

Business Process & Operational Review
We review internal control policies and procedures and determine if errors or irregularities have occurred and the likelihood of them occurring again.

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 that there are adequate controls over financial transactions.

The following services are the result of a medical plan audit:

Contract Compliance Assessment
As a result of performing a medical claims audit, discount audit, business process and operational review and financial reconciliation, HDM 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 proprietary benchmarks.

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