Self-Insured Health Plan Advisory Services
Self-insured health plans offer cost savings and customization. They require demand expertise in financial management, vendor oversight, and regulatory compliance. With over 30 years of experience, Withum’s Self-Insured Health Plan Services Team collaborates with plan sponsors to reduce operational and compliance risks. Our services range from Fiduciary Oversight and medical claims audits to cyber risk assessments.
Health Plan Sponsors Advisory Service Offerings
Medical Claims Audits
Medical claims audits, also called claims audits, healthcare claims audits, insurance claims audits, or third-party administrator (TPA) audits, are important for monitoring and overseeing third-party service providers to a health plan. They help identify opportunities for process improvements, reduce errors and inefficiencies, and mitigate operational and compliance risks for healthcare plan sponsors.
Auditors typically conduct medical claims audits to assess the administration of various types of benefits, including medical, pharmacy, dental, vision, and disability benefits.
- 100% Electronic Claims Reviews
- Focused Claims Audit
- Statistical Claims Audit
- Operation Review
Risk Assessments identify potential weaknesses and gaps in the administrative processes and systems. They allow healthcare plan sponsors to manage risks, put effective controls in place, and protect the integrity, efficiency, and compliance of its health plan.
A manufacturer rebate audit ensures that rebate calculations, payments, and reporting align with contractual terms, regulatory requirements, and industry standards. Key focus areas include verifying rebate data accuracy, reconciling payments with financial records, and assessing compliance with contractual obligations and regulatory guidelines.
Involves reviewing the contracts between the healthcare plan and the service provider. We want to make sure they follow the agreed upon terms, conditions, and regulatory requirements. The goal of the audit is to check that both parties are meeting their contractual obligations. It also aims to find areas of non-compliance or differences, overall reducing risks linked to how the contract performance.
Learn more Compliance Audit of Contract Terms with a TPA or PBM
Assesses the procedures and practices used to determine the individual’s eligibility for coverage under the plan. This review looks at the enrollment process and what documents are required. It also checks how verification is done and what criteria are used to make up decisions. This ensures that individuals are accurately assessed for eligibility based on the health plan’s eligibility rules and regulatory requirements.
Learn more about Eligibility Process Review
Additional Advisory Services
We leverage technology, data analytics, and digital solutions to provide our clients with actionable insights that improve their decision-making.
- HIPAA Assessments
- Litigation Services
- General Healthcare Administration Consulting
- Education and Training
- Cybersecurity Risk Assessments
- ASO Contract Reviews
- Third-Party Vendor Assessments
- Eligibility Process Reviews
+0K
From Plans with 2K to over 600K participants
Self-Insured Health Plans – How We Help
Our team of health plan advisors has worked with plan sponsors of medium to jumbo health plans for more than 30 years. We help health plans manage these responsibilities through a full range of services and technology. Our goal is to mitigate operational and compliance risks. Withum’s Self-Insured Health Plan Services span from Fiduciary Oversight of the Sponsor’s health plan to medical claims audits to cyber risk assessments.
Types of Health Plans We Evaluate
- Medical
- Mental Health
- Prescription Drug
- Dental
- Vision
- Disability
- Health FSA
- Other Ancillary Plans
Success Stories: Helping Transform Health Plans
Case Study: Elevating Healthcare Claim Payment Accuracy
Learn how Withum helped a prominent national multiemployer plan sponsor recover $2.1 million in rightfully owed funds.
Learn More
Case Study: Achieving Financial Stability Through Healthcare Claims Administration Review
Learn how Withum helped improve financial stability and uncovered issues in stop loss administration, leading to successful resolutions through strategic negotiation.
Learn MoreClient Testimonials
Collaborating with Withum proved instrumental in addressing our health plan's challenges. We were experiencing unexplained cost increases that raised concerns among our stakeholders. Withum not only helped us uncover the underlying reasons for these increases but also identified significant errors in the processing of our stop-loss coverage. Their expertise, meticulous approach, and dedication to delivering concrete results have positioned Withum as an invaluable partner. We appreciate their insights and highly recommend their services to any plan sponsor seeking clarity in the administration of their health plan.
Large privately held company
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For more information or to discuss your business needs, please connect with a member of our team.
