Plan Audit and Evaluation

Most self-insured healthplans have hired an outside organization to provide services on behalf of their members to include: Claims Processing, Enrollment Processing, Customer Service, Clinical Case Management, Disease Management, Stop Loss Insurance, Regulatory Compliance, etc.

PIC recommends that the service vendors be audited annually to ensure adherence to the Plan and the Plan Sponsor's intentions.

The primary goal of the performance evaluation is to examine all of the services offered by the administrator and any of their subcontractors (or targeted services) to ensure that the services are provided appropriately and in accordance with industry standards.

Examples of areas important to audit include:

Enrollment Accuracy,
Claims Payment Accuracy,
Provider Payment Confirmation,
Disease Management Enrollment and Follow Up, and
Case Management Outreach and Follow Up

As part of the overall improvement program, PIC has partnered with the APEX Management Group, a division of Gallagher Benefit Services, Inc., to conduct Plan Audits and Performance Evaluations.

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