A healthcare plan audit program
to safeguard your plan assets
is a Best Practice

Health Care Plan Audits: Do You Know?



  • That as a sponsor of a self-funded health care plan, you have a fiduciary responsibility to your plan participants. Many plan sponsors protect their health care benefits plan’s
    by engaging MedReview to perform health care plan audits that
    will help them meet ERISA, Sarbanes-Oxley and other regulatory

  • That most TPA’s adhere to a “Pay and Pursue” philosophy when handling subrogation or CoB claims for your plan? A MedReview audit requires documentation from your TPA showing that the claim was paid correctly.

  • That TPAs expect third party audits. TPAs have departments specifically designated to administer external audits. Your TPA or ASO agreement normally addresses your audit rights. MedReview gives your TPA an opportunity to review all audit reports and to respond. These responses are included in your final audit report.

  • Your TPA’s internal health care audit program may never include a claim from your plan.

  • With the exception of a Dependent Eligiblity Audit, employees are seldom impacted by the results of an audit. If MedReview discovers an issue that could negatively affect a plan member, you decide whether or not to pursue the recovery of the overpayment.

  • As TPAs and PBMs upgrade and modify business systems and practices, the risks of reporting and processing accuracy issues increase. Your ability to predict expenses and manage costs is impacted by your TPA’s and PBM’s business practices.


  • Our average Dependent Eligibility Audit determines that 6% of all dependents on your company health plan are ineligible. The lowest result we have found is 4% and the highest result we have found is 16%.