• Focused Sample Claim Audits
• Random Sample Claim Audits
• Pre-Payment Claims Audits
• Operational Reviews
• Pharmacy Audits
• Dependent Eligibility Audits

Operational Reviews

 

Operational Reviews examine the processes, procedures and systems that your Third Party Administrator ("TPA") utilizes to pay your medical claims.

 

The following is a partial list of the areas our Operational Reviews examine:

• Staffing, training and supervision of claims payers.
• Systems and Software.
• Processing of facility claims.
• Processing of professional claims.
• Coordination of benefits.
• Subrogation.
• Quality Control/ Internal Claims Audits.
• Timeliness of claims payments.
• Performance Standards reporting.

MedReview's Operational Reviews focus on any specific concerns you may have. For example, we will review in detail the process used by your TPA to update employee and dependent eligibility.

Operational Reviews are fixed fee audits. The amount of the fee is based upon the number of employees in your plan.

Conducting an Operational Review enables you to grade the performance of your TPA and to work with your TPA to correct any problems that exist.

An Operational Review may be combined with any of MedReview's other medical claim audits. For example, combining an Operational Review with a Focused Sample Claim Audit enables the plan sponsor to recover all or part of the Operational Review fixed fee due to the overpayments we recover as a result of the Focused Sample Claim Audit.