Case Study: Healthcare Expense Management, Audits and Contract Compliance for a State Government

We perform independent, unbiased audits of your health plan expenses to save you money, and keep your TPA compliant with contractual provisions and financial standards.

CLIENT NEED

Benefits Plus Consulting Group, Inc. was retained, as a subcontractor, by a large prime contractor on a five-year Medical Plan Audit contract for an east coast state. The medical plan serves approximately 165,000 members. The state required independent audits of ten administrators that managed its self-insured medical, prescription drug, dental, mental health and flex-spending programs, in order to ensure compliance with contractual provisions and to help claim any cost recoveries for substandard performance.

BENEFITS PLUS CONSULTING SOLUTION

• Performed on-site audits to monitor administrator compliance with performance guarantees for each contract fiscal year.
  
• Coordinated a highly qualified, state-based clinical team to perform on-site audits of case and disease management programs.
  
• Drafted case and disease management reports that were integrated with claims, eligibility, and benefits-data analysis.
  
• Participated in annual meetings with the State’s fiduciaries and ten administrators to review and agree to findings and cost recoveries.
  
• Resolved any discrepancies to expedite the issue of final reports.
  

RESULTS

The Benefits Plus Consulting Team continued to perform this audit and reporting work for one full five-year contract term, despite two acquisitions of the primes involved, and was retained again for the second five-year term.

^{Case studies presented are not indicative of all client experience with Benefits Plus Consulting Group, Inc. Each client has unique circumstances and the case studies presented are only meant to illustrate common issues encountered by our clients and the methodology we follow. Case studies presented should not be interpreted as a guarantee of future success.}