We help you ensure proper and efficient benefit claims management.
Management and boards that oversee plans providing health benefits are responsible for ensuring they operate in the best interest of plan participants. Routine claims testing allows fiduciaries to detect problems, identify underpayments to participants or providers, and recover overpayments. In addition to uncovering claim payment or pricing errors, examiners may pinpoint system errors that could result in widespread or ongoing inaccuracies.
We provide services to health benefit plans that cover:
- Medical Benefits
- Dental Benefits
- PPO Pricing
Among other things, a claims audit tests benefits for the following:
- Participant Eligibility
- Coordination of Benefits
- Input Errors
- Overpayments and Underpayments
- Duplicate Payments
- Contract Pricing
- Unbundled Billing Codes
- Usual and Customary Practices
- Third Party Liability
- Plan Maximums
- Application of Deductibles and Co-Payments
- Out-of-Pocket Expense Caps
We maintain a team of full-time specialists who have extensive experience with self-funded benefit plans; we work directly with plan personnel and third-party administrators (TPAs). Claims examiners adhere to the Health Insurance Portability and Accountability Act (HIPAA) when working with Protected Health Information (PHI).
Each examination is tailored so our procedures specifically address your plan’s rules and operations. In addition to a summary of over- and underpayments, our report includes observations and recommendations regarding processing or system concerns identified during testing.
