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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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 [...] 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 [...] 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 [...] 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 [...] 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 [...] 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 [...] |
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