Many companies, both large and small, do not have proper measures in place to confirm that their medical plan funding is being handled properly and at its best. Medical claims are often overpaid, are paid for services not covered by the provided plan, or are paid for patients who are no longer eligible for such coverage. Given this, the enormity of escalating medical plan costs, and the increase in corporate responsibility, it is even important to verify if your medical plan funding is being dispersed properly.
Self-insured employers require assurance that plan administrators are consistently paying medical claims accurately and appropriately, according to plan design and terms of the administrative agreement. To achieve this goal, HDM conducts a comprehensive review of plan administration, including paid claims and provider discounts. Through this process, HDM will:
| . Determine compliance with both contract terms and plan documents. |
. Assess financial accuracy of paid claims and administrative processes,
including error and fraud detection. |
. Evaluate accuracy of payments and identify overpayments, duplicates
cost savings prospects. |
. Identify control weaknesses, their causes and suggest process enhancement/
cost savings prospects. |
| . Assess provider network penetration, utilization, and discount. |
| . Review client's role regarding administration and offer recommendations. |
| . Identify, validate, and recover overpayments. |
The following services can be included in a medical plan audit:
Claims Audit
HDM analyzes 100% of medical claims according the contract, summary plan document and industry standards and then performs an onsite claims audit to validate findings and determines the discount arrangement that clients are entitled to through contracts with administrators and fulfillment verification of contract requirements by the administrator.
Business Process & Operational Review
HDM conducts an onsite operational review at the administrator's facility to evaluate the control environment and assess the risk of fraud or error. We review internal control policies and procedures and determine if errors or irregularities have occurred and the likelihood of them occurring.
Financial Reconciliation
HDM performs a financial and funding reconciliation, utilizing administrator reports and customer banking records. We review adequacy of the funding requests and reconcile all funding and payment banking records, thus assuring that there are adequate controls over financial transactions.
The following services are the result of a medical plan audit:
Contract Compliance Assessment
As a result of performing a claims audit, discount audit, business process and operational review and financial reconciliation, HDM will assess contract compliance with emphasis on summary plan description, reporting and contracted services. HDM will recommend contract changes based on best practices derived from our wealth of experience.
Recovery of Overpayments
HDM will present validated claim errors and overpayments to the administrator for recovery, as well as, negotiate and monitor recovery collection activity to ensure recovered dollars go to our client.
To learn more about our cost containment solutions for self-insured employers, contact HDM today at 800.859.5119 or request information with our online form. You may also send an email to: info@HDMinc.com.
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