Many self-insured employers do not think about their dental plans until they notice increasingly burgeoning costs. Verifying correct usage of dental plans is made even difficult through out-dated and inflexible computer systems, misuse by participants, incorrect administrating, and wrongful use of the plan due to lack of information or understanding.
Self-insured employers need assurance that plan administrators pay dental claims accurately and appropriately according to plan design and terms of the administrative agreement. To achieve this goal, HDM conducts a comprehensive review of plan administration, including paid claims, provider discounts, and the following:
| . Determine compliance with both contract terms and plan documents. |
| . Assess financial accuracy of paid claims and administrative processes, including error and fraud detection. |
| . Evaluate accuracy of payments and identify overpayments, duplicates cost savings prospects. |
| . Identify control weaknesses, their causes and suggest process enhancement/cost savings prospects. |
| . Assess retail and mail order programs. |
| . Review client's role regarding administration and offer recommendations. |
| . Identify, validate, and recover overpayments. |
The following services can be included in dental plan audit:
Claims Audit
HDM analyzes 100% of dental claims according the contract, summary plan document and industry standards and perform 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 procedure 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 wealth of experience.
Recovery of Overpayments
HDM will present validated claim errors and overpayments to the administrator for recovery, as well as, negotiate and monitor recovery collection activity to ensure recovered dollars go to our client.
To learn more about our cost containment solutions for self-insured employers, contact HDM today at 800.859.5119 or request information with our online form. You may also send an email to: info@HDMinc.com.
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