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Our Evaluation
Services Include:
  • Targeted Claims Evaluations

  • Snapshot Analysis

  • Focused Claims Assessments

  • Random Claims Evaluations

  • Ineligible Dependent Review

  • Claims Operations Review

    1. System Security

    2. System Segregation Access for Employees

    3. Claim Control

    4. Refund/Returned Check Controls

    5. Outgoing Check Controls

    6. Pended/Denied/Appealed Claims Review

    7. Fraudulent Providers

    8. Overpayments

  • Retirement Account Evaluations

  • Administrative Operations Evaluations

  • Stop-Loss Inspections

  • Litigation Support

  • Fraud Investigations

  • Operational Controls Reviews

  • Follow-Up Evaluations
  • Benefit Plan Audit Services (BPA) is a full-service firm, specializing in the evaluation of benefit plan payments, procedures, and controls. We offer a complete line of services, to provide you with the results you need so you can find out if your administrator is really "looking out" for your healthcare costs. After all, "What You Want, We Want."

    Among our customized services, we provide the following types of evaluations:

    • Targeted Claims Evaluations — This is where we can "show you the money" your administrator is throwing away. We select a targeted sample of paid claims, focusing on high dollar claims and claims for services which are most likely to include overpayments. Since our sample is skewed to save you money, the results will not give you a statistical rate to measure your administrator's overall performance. But, you will get the "biggest bang for the buck" if you want to find out where your "lost dollars are buried." (top)

    • Snapshot Analysis — Do you want to get an idea on how well your administrator is doing right now, while not spending a lot of money to find out? This is our economical alternative. For a low fee, we'll do an analysis of a smaller volume of claims than our normal evaluations, for a limited scope period. These assessments usually cover 75-100 claims paid during one month. The results are not statistically valid due to the limited sample size, but this analysis will give you a feeling for how accurate your claims are being paid right now, all for a budget-friendly fee. (top)

    • Focused Claims Assessments — Do you have a specific area of concern with your administrator? Are you seeing your benefit costs skyrocket in certain areas? We will customize our evaluation to meet your concerns. (top)

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    • Random Claims Evaluations — How accurate are your health care claims being paid? We evaluate your medical, dental, vision, pharmacy, and/or flexible spending account claims by tailoring our standard random claims evaluation to fit your concerns. Our standard sample is 150-225 claims. However, you can set the sample size and scope period to meet your needs. Our evaluations stratify your file into meaningful payment bands, and use random sampling to adequately represent your entire claims payment population. We extrapolate the results over your claims payment history, so you can see where you may be losing money. We also give you statistically valid weighted average extrapolated percentages for financial and procedural accuracy, and claims turnaround time, so you can see exactly how your administrator measures up against industry standards, and any contractual performance goals you may have. (top)


    • Ineligible Dependent Review — How many dollars are you wasting on ineligible dependents who are not qualified to receive benefits under your plan? Do your employees always let you know to delete dependents when they get a divorce, when their children graduate from college, or when some other life event causes their dependents to no longer meet your eligibility guidelines? Are you sure that new child added to your plan was your employee's son, and not a new nephew? Benefit plans are spending millions of dollars annually paying health benefits for ineligible dependents. You can lower your soaring health-care costs by letting us help you identify ineligible dependents covered under your plan due to misunderstanding, abuse or fraud.   (top)

    • Claims Operations Review — What really is happening there? Is something going on in that office? Why are our claims not being paid on time? In addition to claims payment administration, there are many other operations within your administrator's office that can affect your organization's claims costs, and increase your financial exposure. This is why we offer this service. We will perform an on-site visit to review your administrator's internal operations, to make sure your organization's money and resources are not at risk for unnecessary exposure. The review will include, but not be limited to, the following areas:   (top)
    1. System Security: How secure is your administrator's system? We will review your administrator's system security to make sure they minimize your exposure. (top)

    2. System Segregation Access for Employees: Do you want someone paying claims to also be adding providers, adding or changing member or provider addresses, or doing eligibility changes? Chances are, NO! We will review claims system access to assure there is a proper segregation of system functions for your administrator's staff. (top)

    3. Claim Control: What happened to the claim I sent? I sent it three times! We will review the administrator's claim control, from claim entrance to claim exit, to identify any claim control weaknesses. (top)

    4. Refund/Returned Check Controls: Do you ever wonder if you actually get your refund checks timely, or if returned checks are being sent to you timely? This, in some cases, results in lost cash flow for you. We will review controls over refund and returned checks to assure proper control and timely processing. (top)

    5. Outgoing Check Controls: After the check prints, what happens next? We review controls to make sure your administrator minimizes the exposure of your checks and bank account information. (top)

    6. Pended/Denied/Appealed Claims Review: Did you ever get a letter from an attorney about a denied/delayed/appealed claim? Let's face it, they are becoming more and more numerous in today's litigious society. We will review a sample of your organization's denied, pended, and appealed claims to make sure your plan complies with ERISA and other regulatory mandates. (top)

    7. Fraudulent Providers: How much money are you paying to fraudulent providers that don't even exist? Millions of dollars in fraudulent claims are submitted, and paid, each year. Does your administrator have the proper controls in place to detect and possibly prevent your money from being stolen this way? If not, we can help identify the controls that need to be put in place. (top)

    8. Overpayments: How much money has my administrator overpaid? Am I getting the money they overpaid back? We will review your administrator's collection procedures, and, if you prefer, we can handle overpayment follow-up and collection procedures for any claims overpaid $500 or more, on a contingency fee based on collections we recover for you. (top)
     

    BPA Also Offers These Additional Kinds of Evaluations:

    • Retirement Account Evaluations: We will evaluate your defined benefit (pension) and/or defined contribution (401(k) or annuity) plan payments and controls, to assure your administrator is accurately paying the benefits you issue. We review a sample of payments for both the accuracy of calculations, and the adequacy of documentation obtained to support the payments. We also review the controls surrounding these disbursements, to make sure your administrator has proper procedures and controls to protect your assets. (top)

    • Administrative Operations Evaluations: For these evaluations, we review the controls and accuracy of all services your administrator provides you. This can include reviewing everything from the accuracy of the invoice for the administrator's fee to you to the timeliness and completeness of documentation for regulatory and tax filings they perform. We can review any accounting they perform for you, from the accuracy and timeliness of bank reconcilements, to controls over your checks, signature plates, and wire transfer authority. We can review their calculation of your stop loss and other insurance premium calculations, and any premium billing, contribution accounting, or COBRA billing and cash collection procedures they perform. We will tailor our operations reviews to your areas of concerns, and the functions the administrator is contracted to perform for you. (top)

    • Stop-Loss Inspections: Every day, third party administrators fail to follow the rules set up with their stop loss carriers. By not notifying the carrier timely when claims are approaching the specific attachment limits, claims for reimbursement are denied and do not get paid. That can cost your plan plenty, if you think you have stop loss coverage, only to find out you cannot get reimbursed due to the administrator's lack of effective procedures. We will look at the stop loss contract, and the procedures your claims processor or third party administrator have set up, to make sure proper controls are in place to identify high cost claims, and notify the carrier at the proper time, so claims are not denied unnecessarily. (top)

    • Litigation Support: If you are involved in litigation involving benefit plan administration, we can help. If you are taking action against your administrator for payment or other errors, we can provide the support you need to identify the extent of your losses, to help you in your claim for damages. If you are defending your plan against unfair charges, we can review the results of the plaintiff's auditors, to refute errors they charged unfairly, and identify mistakes they made either procedurally or in calculating their results. (top)

    • Fraud Investigations: Healthcare fraud is now estimated at over $100 Billion each year. How many dollars is your plan losing to fraud? We can help identify provider fraud schemes that may be affecting the claims your plan is paying. We can also investigate if you have any concerns about fraud in your administrator's office. (top)

    • Operational Controls Reviews: By now, you've probably heard about Statement on Auditing Standards (SAS) #70. This standard imposed the requirement that CPAs must determine that proper controls exist at any third party service organization that processes transactions that affect your financial statements. Since your administrator handles your funds, their actions affect your financial statements. Thus, they need to have an independent party review their control environment, accounting system, and control procedures. We can support the third party administrator by performing an operational controls review that tests the operating effectiveness of their controls. The reviews involve identifying the processes and procedures that make up the internal control environment, and then testing the procedures to make sure they are functioning effectively.(top)

    • Follow-Up Evaluations: Most audit firms and consultants are interested in your business. But, you don't see or hear from them again, until they contact you next year to contract with you for another review. We know that things change quickly, and you are interested in the money flowing through your benefit plans constantly, not just once a year. That is why we will contract to perform regular quarterly or semi-annual follow-up evaluations, to make sure adequate corrective action is being taken on any findings we uncover, and to make sure areas that are in control, stay in control. (top)

    We know you want to find out if your claims administrator is looking out for your health care costs. And, before you spend money to partner with a firm to evaluate your administrator, you want to make sure the firm you hire handles your assessment and consulting assignments in a top-notch professional manner. We understand what you want, and we know our professional handling of your business is one of the most important ways we can help you. At Benefit Plan Audit Services, we provide the highest level of professional services, because "What You Want, We Want."

    We can help you save money by reducing your health benefits claims expense.
    Please click here to email us for more info: info@beneplanaudit.com.

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    Benefit Plan Audit Services, LLC
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    Contact: Robert Frcek
    961 Amherst Avenue
    Los Angeles, CA 90049 USA
    Phone: (310) 629-5372
    FAX: (310) 442-2859
    Email: rfrcek@beneplanaudit.com


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