Services

If you are a self-insured company, your group health-plan costs probably rate among your most significant operating expenses. In today’s health care environment, it’s clear these costs will continue to rise - making it important to have the proper controls in place to monitor this investment.

How we can help
At RSM McGladrey, our experienced consultants work with you to document and evaluate your health claims administration processes. Our claims administration review services are designed to help you properly execute agreements with third party administrators (TPA) and pharmacy benefit managers (PBM).

We assist you in determining whether reasonable internal controls are in place for existing administrative functions, including claims processing. At the same time, we focus on limiting financial reserves exposures and enhancing the self-reporting relationship. Our goal is to help you effectively manage your fiduciary responsibilities, while reducing future health care costs.

To conduct a claims administration review of your TPA, our consultants use a methodology that combines contract compliance, internal control and individual health claim file analysis. This methodology includes:

• Evaluating TPA performance against contractual guarantees
• Enhancing operational and internal controls over self-reporting vendor services
• Validating claims payment and procedural accuracy and reserving levels
• Controlling health care benefits spending

We work closely with your benefits team and TPA to gather information through interviews, observation and existing formal document and claims re-adjudication. Our process includes five phases:

• Phase 1 – Gain an understanding of the review plan, and agree on scope, key objectives and deliverables.
• Phase 2 – Conduct a diagnostic review of processes to better understand how you and your TPA and PBM currently work together.
• Phase 3 – Conduct a claim file review against defined attributes.
• Phase 4 – Summarize findings and calculate performance measures for TPA and PBM, including a comparison to industry norms.
• Phase 5 – Issue final deliverables, including a written report of the scope and engagement findings,a summary of the claim file and our observations and recommendations.

We also work with our healthcare risk advisory group to provide the services that best fit your needs. With more than 200 years of combined experience, this group understands the payment issues and contractual commitments associated with TPAs and PBMs.

Our team has extensive knowledge and experience working with self-insurance plans, insurance companies, TPAs, PBMs, as well as providers. As a result, we have a full-cycle approach to health care management that not only meets your objectives, but provides additional insight on issues you may not be aware of in today’s environment.