Audit
Plus
“Follow the money.” – Deep Throat
It may be easy to assume that an audit is an audit
is an audit, but that is not the case!! Our Audit Plus
service is a comprehensive health cost recovery review
that, through The BRAIN A
Comprehensive Suite of Integrated Services), also forms
the basis for evidenced-based cost containment
analysis and support. Our multi-disciplinary team of
experienced professionals evaluates all
the health plan related data, identifies likely errors
electronically, validates and documents confirmed
amounts due the plan sponsor with the appropriate vendor
and facilitate recoveries or credits on behalf of clients.
Most health plan administrators accept that there
is a 1.5 % - 3% error rate in their claims payment
processes. (The Wall Street Journal reported results
of a study earlier this year that found up to a 6%
error rate.) A 3% error rate, implying a 97% accuracy
rate, may be an “A+” in school, but that
doesn’t mean plan sponsors shouldn’t seek
to recover the erroneous payments.
One of the key differences between Audit Plus and other
approaches is that our methodology uses 100%
of the data from all available sources to
evaluate the accuracy of processes with financial
impacts within the workings
of each health plan. Our Audit Plus process tests the
financial experience of each plan against plan provisions
and the terms of its vendor agreements using complete
data sets for:
- Eligibility
- Enrollment
- Medical claims and claims from any carved-out
coverages such as pharmaceuticals and mental
health benefits
- Reinsurance
- Subrogation
- Coordination of benefits
- COBRA administration
This means we leave no stone unturned in seeking
to maximize recoveries for clients.
This is a major difference
from most health benefit audit approaches,
which use a sampling method to focus on
a limited number
of claims
with varying characteristics (stratified)
or with diagnostic codes the audit firm feels
may be problematic.
These
approaches leave room for oversight
of significant claims errors.
Audit Plus standard data test areas include:
Member
Eligibility
Claims Eligibility
Financial Accuracy
Reasonable & Customary Compliance
Plan Limits & Exclusions
Compliance
Subrogation
Reinsurance Administration
Coordination of Benefits
The circumstances of different plans, information
we uncover in initial tests and the plan sponsor’s
industry all influence the selection of additional
tests we have available.
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