An Employer's Guide to Health Care Cost Containment » ASO Agreements

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 [...]

Dependent Eligibility: Reading Between the Lines

Tony Schy — Thu, 22 Jan 2009 21:24:52 +0000

Paying claims for members that are no longer eligible is more common than most organizations realize. Timely management and communications of enrollment data can present major challenges. While some processes are tightly managed and produce virtually no overpayment, others are poorly defined, loosely managed and have no built-in checks and balances. Because of this, you should read carefully the language in your ASO Agreement related to the management of eligibility data. In particular there are three things to closely [...]

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