An employer with a self-insured medical, dental, or prescription drug plan should consider a claim audit at least every other year – more often if issues have been identified. An audit is a prudent, fiscally responsible step that should be a part of an employer’s ongoing vendor management efforts.
Performance can vary not only from administrator to administrator, but also from plan to plan within an administrator. If you want your plan to be the one that receives extra attention from the vendor, then periodic audits and validation of performance guarantees will let the vendor know that you are taking an active role in plan management.
In addition to performing periodic audits of your healthcare plan administrators, you should also consider an audit if:
- You have never conducted an audit of your administrator
- Claim costs have significantly increased without explanation from your administrator
- Issues were identified in a previous audit
- Recent changes within the administrator’s organization
– System conversion
– Claims, customer service, or account management staffing changes
- There have been issues/delays in implementing plan design changes
- Your plan design has complex elements that require manual intervention by the administrator
- The same issues are repeatedly brought to your attention by your employees