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 [...]
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Self-Insured employers have the opportunity to recover a substantial amount of money from a recent settlement regarding Average Wholesale Price and how it was used to pay pharmacy claims between 2001 and 2005. However, claims must by filed by July 9th 2009. Read more about the opportunity at the AWP McKesson Settlement website. 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 [...] 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 [...] 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 [...] |
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