An Employer's Guide to Health Care Cost Containment » Medical Claim Audit

What is Voluntary Data Share Agreement (VDSA)?

Jennifer Posey — Wed, 30 Jun 2010 14:42:35 +0000

The Centers for Medicaid and Medicare Services (CMS) instituted the VDSA program to provide better communication between itself, employers and insurers. This exchange of information ensures all parties, including Medicare, have all necessary information to determine which insurance company should be paying medical claims first.

Employers who sign a VDSA with CMS will provide a quarterly [...]

Choosing Your Health Care Claim Audit Approach

Jennifer Posey — Mon, 21 Jun 2010 17:24:46 +0000

When considering a claim audit there are several approaches that can be taken. The most traditional type of audit is retrospective in nature and includes the most recent 18-24 months of claims. Retrospective audits can be performed differently depending on the employers audit objective. Understanding your objectives and clearly defining those objectives will aid in [...]

Why Employers Should Require Medicare Enrollment in Their Summary Plan Descriptions

Tanya Henry — Thu, 27 May 2010 19:53:25 +0000

As an employer you may believe that not requiring your Medicare eligible population to enroll in Medicare is somehow a benefit to your employee. You may believe that you are not allowed to force your Medicare eligible members to enroll. However, both of these statements are false.

How does mandatory Medicare enrollment work? As an employer [...]

Coordination of Benefits Rules are Commonly Misunderstood

Angela Travis — Wed, 06 May 2009 18:25:05 +0000

Most people are not aware that there are laws that govern Coordination of benefits. In my experience, most consumers think they can just pick which Insurance carrier that they want to be primary. For example, a spouse on a plan may also carry his/her own coverage through their employer. However, that policy may have a [...]

6 Reasons Your Benefit Plan Might Be Ready For A Claim Audit

Tony Schy — Tue, 10 Feb 2009 14:42:41 +0000

The motivations behind why an organization might consider conducting a claim audit are endless. However, below are the 6 most common:

Compliance/Sarbanes Oxley/Fiduciary Obligation: Most organizations retain a fiduciary obligation to operate the plan in the best interest of the plan participants. Health benefits usually represent a large expense. Making sure that shareholder resources are being [...]

Medicare Language in your Plan Design Documents

Michael G. Browning — Wed, 04 Feb 2009 15:19:01 +0000

Coordination with Medicare is one of the more challenging processes for many third-party administrators. Many times they are unaware if your employees are carrying Medicare or are eligible to receive it and are not signed up for coverage.

This can be a significant and costly problem for your company when you have active employees who are also [...]

Determining Your Best Claim Audit Approach

Tony Schy — Mon, 26 Jan 2009 14:06:28 +0000

3 Steps to Determine the Best Claim Audit Approach

If you are contemplating a claim audit project, below is a 3 step process to guide you toward making the best choice for your organization.

Step 1: Clearly understand your objectives. There are wide array of options available and the only method to figure out which is the [...]

10 Claim Audit Roadblocks You Should Consider

Tony Schy — Fri, 23 Jan 2009 15:24:27 +0000

When an employer is considering a Medical, Pharmacy or Dental Claim Audit, it is important to understand the most common roadblocks to an effective process. Understanding the following points will allow you to properly prepare for an audit of your Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM).

Limitation of sample size: most ASO Agreements [...]

The Top 11 Things You Should Do to Maintain Your Claim Audit Rights, Part 2 of 2

Tony Schy — Fri, 16 Jan 2009 14:05:36 +0000

Most plan sponsors don’t think about audits when negotiating or renegotiating an ASO Agreement with their third party administrator. However, taking the time to ensure that your audit rights are protected is a wise move. Doing so will save time and lead to a more positive audit experience when the time comes to conduct your [...]

The Top 11 Things You Should Do to Maintain Your Claim Audit Rights, Part 1 of 2

Tony Schy — Thu, 15 Jan 2009 15:32:18 +0000