DOES YOUR PLAN NEED A CLAIM AUDIT?
To find out if your plan needs a claim audit, try asking yourself these questions...
- Is our program being administered as effectively as possible?
- If I accept a specific error rate, do I know that the control ratio is being properly determined? How many dollars are at risk?
- Does our Administrator have adequate internal controls and audits?
- Are specific areas of our plan being abused because of ineffective procedures?
- Are specialty claims (chemical dependency, mental health, etc.) being handled in the best interest of the employee and the company?
- Am I getting too few complaints from our plan's cost containment provisions?
- Are there refund checks from providers for overpayments? Did the Administrator request them?
- Has the service contact or claim examiner at our Administrator changed frequently?
- Did our Administrator install new computer software or hardware?
A "YES" to one or more of the questions indicates it's time to audit your Administrator.
BENEFITS OF AN AUDIT
In addition to saving your plan money by finding costly repetitive payment errors, the ICAPS audit has other benefits...
- It tells you about the administration of your present plan:
- Do current systems effectively administer your plan?
- What areas of your plan are being abused because of ineffective procedures?
- It informs you how the plan is being managed by your Administrator:
- What percent of the claims are being processed incorrectly?
- If you accept a specific error ratio, is the control ratio being properly determined?
- It determines if a claim is paid correctly and if not, why not:
- Are documented policies and procedures in place?
- Was the plan loaded correctly?
- Is the Administrator's staff properly trained?
- Are system controls capable of monitoring the plan?
- What percent of internal claims have been audited? What are the results?
- It provides suggestions to improve the plan by:
- Identifying specific problems and recommending solutions
- Improving communications between you and your Administrator
- Being an independent expert, no inherent conflict of interest
- Assisting in the development of a Performance Agreement