Archived Insight | November 22, 2019
Since 1973, Segal has conducted scores of retrospective on-site claims reviews of public sector health plans administered internally or by third-party administrators. Our consultants have extensive background in claims processing and operational reviews.
This experience makes them uniquely qualified to evaluate established administrative procedures, suggest areas for improvement and ensure proper controls are in place for efficient plan administration.
We'll will work with you to determine what your greatest challenges are. We can target our reviews to the areas that make an impact on the bottom line or that best support your plan's overall goals.
We tailor each claims auditing project to the plan's specific concerns and objectives. We offer an array of services and tools relating to claims adjudication of all plan expenses (i.e., medical, dental, disability, vision, life insurance).
They include the following.
Consider an audit if your plan:
Strategies and recommendations for eligibility audits vary based on group size and benefit philosophy.
Segal can help plan sponsors establish appropriate controls to ensure that benefits are only paid for eligible participants and dependents.
Nationwide estimates suggest that eligibility errors are prevalent in health plans.
In fact, eligibility audits are reported to produce 10 - 15% reductions in the number of eligible dependents.
To protect against financial losses, it is imperative for group health plans to use eligibility safeguards and perform audits.
We can conduct eligibility audits to identify:
Segal can work with you to determine an appropriate approach for your plan’s dependent eligibility verification.
For example, a strict audit terminates dependent benefits until confirmation of their eligibility is received, while a much softer approach asks employees to sign a statement confirming dependent eligible status.
Segal can assist with the following.
We'll coordinate with plan sponsors to describe the overall process, outline management decision points and collect information required to request proposals.
The RFP process can be formal or modified to enlist proposals from industry leaders.
Segal will coordinate with plan sponsors from start to finish, outlining project objectives and required deliverables, monitoring vendor performance to ensure timely completion of all projects and determining if additional outreach steps may be required.
We'll coordinate with plan sponsors so that procedural changes for the intake of new dependents ensure consistency for all enrollees.
This page is for informational purposes only and does not constitute legal, tax or investment advice. You are encouraged to discuss the issues raised here with your legal, tax and other advisors before determining how the issues apply to your specific situations.