Audit and Compliance

Audit and Compliance: two words that very few people love. Luckily, our team is cut from a different cloth. We are experts in Audit and Compliance, and we pride ourselves on our use of unique data hierarchies and critical thinking in the areas of audit and compliance. We work diligently with our clients to explain administrative, financial, and strategic implications of the law and emerging regulations. We proactively offer analysis and interpretation on both the intended and unintended consequences for plan sponsors. We provide tactical and strategic thought and advice for each client based on their specific circumstances.

Our Applied Quantitative Analytics (AQA) combines the talents of our diverse group of experts with our market-unique, proprietary audit tool. AQA is powerful. It identifies aberrant clinician utilization, referral, and billing practices. Claims are indexed by service type and modality, correlated to reimbursement mode by provider, and adjusted to local practice patterns. AQA finds and quantifies the causes and costs of “claim leakage” and the effects of provider revenue cycle enhancement. It examines clinical practices, costs and outcomes by provider.

AQA’s capabilities make it an invaluable audit tool, bringing transparency to provider behavior and carrier management skills. It enables remuneration of previously made inappropriate AQA payments and also identifies efficient, high quality providers for use by plan sponsors, participants and network entities. AQA’s value-add to clients will only continue to grow as Health Care Reform results in provider network reconfiguration and CDHP requires increased information to be placed in the hands of the participant.

Additional audit and compliance services include, but are not limited to:

  • Authoring and release of legislative and regulatory updates;
  • Provide assistance and advice with review of benefit programs on a continuing basis to ensure compliance with federal requirements and adequacy of benefits with respect to other plans;
  • Provide information on pending or new legislation and changes in tax law, as well as benefit and funding trends that may affect the benefits program, applying assumptions to various scenarios;
  • Audit, develop, and document appropriate client policies and workflow for regulatory compliance;
  • Conduct administrative, operational, and clinical vendor audit, which also includes review of data security and internal audit and controls;
  • Perform discrimination testing for insured and non-insured arrangements;
  • Advise and assist the client with writing plan modifications and new plans, submitting written reports, and other documents as required by the Federal Government;
  • Assist with required filings such as Form 5500s, ERRP, and minimum credible coverage;
  • Review all plan documents, contracts, insurance policies, and employee communication for accuracy, applicability, and consistency.