Targeted Claim Audit
Integration of services
Statistically 20% of participants produce 80% of a Health Plan’s spend. Those participants with advanced treatment protocols require layers of adjudication to verify appropriate care and controlled expense.
CBA can help evaluate the administrator’s integration of services within their adjudication process and work closely with them to identify areas for improvement that frequently translate to significant savings opportunities.
Randomized Claim Audit
Meeting the standards
Management of administrative relationships requires the establishment of clear responsibilities and measures of accountability between the Health Plan and their administrator.
Confirming that procedural and financial accuracy meet established standards is essential, as unmeasured accuracy can present substantial liabilities.
CBA can determine a valid selection of random claims and audit for consistent and quantifiable performance standards that assure quality benchmarks are met.
Strong, reliable, trusted relationships
CBA understands that statistics alone cannot comprehensively report the qualifications of an administrator – it’s always the people and the process.
If there are issues that affect implementation of services or coordination of resources, it’s qualified people that determine the solution.
CBA has the ability to ask the right questions of the right people to isolate issues and influence solutions. This person to person approach empowers the Plan and the administrator, and results in strong, reliable, trusted, long-term relationships.
Pharmacy Benefit Audit
A technological and analytical approach
Prescription drug usage and cost directly and significantly affect a Health Plan’s bottom line at an ever-increasing rate. Controlling the complex formularies, fee structures and rebating requires a detailed understanding of the players involved. This complex array of factors makes it challenging for Health Plans to verify programs are operating cost effectively.
CBA provides a coordinated effort that brings an analytical approach to isolate areas of concern and provide guidance on corrective actions when negotiating your Pharmacy Benefit Manager (PBM) arrangement.