Medical Plan Audit

Self-insured employers require assurance that plan administrators pay 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. 

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.  

Discount Audit

Determine the discount arrangement that customers are entitled to through contracts with administrators and then verify fulfillment of contract requirements by the administrator.

Business Process & Operational Review  

Onsite operational review at the administrator's facility to evaluate the control environment and assess the risk of fraud or error. Review internal control policies and procedure and determine if errors or irregularities have occurred or the likelihood of them occurring.

Financial Reconciliation

Perform a financial and funding reconciliation, utilizing administrator reports and customer banking records. Review adequacy of the funding requests and reconcile all funding and payment banking records. Thus assuring there are adequate controls over financial transactions. 

Contract Compliance Audit

As a result of performing a Claims Audit, Discount Audit, Business Process & 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  

Present validated claim errors and overpayments to the administrator for recovery. Negotiate and monitor recovery collection activity to ensure recovered dollars go to our customer.

If you have questions about this web site or need assistance e-mail info@hdminc.com or call 1-800-859-5119.

 

Types of Audits

Medical Plan Audit Pharmacy Plan Audit Dental Plan Audit Hospital Bill Audit Eligibility Audits

Value by Department

Corporate Finance HR/Benefits Internal Audit IT Department Healthcare Vendors Consultants

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