OPERATIONAL REVIEWS

An Operational Review examines the process, procedures, and policies used by the plan administrator to pay your medical claims. It is not just a general review but is focused specifically on your claims and how they are processed.

Some of the areas we examine are:

• Staffing, Supervision, and Training
• Systems and Software
• Processing of Facility Claims
• Processing of Professional Claims
• Coordination of Benefits
• Identification of Third Party Liability
• Quality Control / Internal Claims Audit
• Timeliness of Claims Payment
• Performance Standards Reporting

After an Operational Review, a plan sponsor knows exactly how claims are handled and can easily identify shortcomings and work with the plan administrator to make needed corrections.

An Operational Review can be combined with a Focused Sample Claims Audit, a Random Sample Claims Audit, or with an Electronic Audit of All Claims Paid.

Operational Reviews do not need to be conducted every year. They are intended to be done every three years or one year after changing plan administrators. We have, in some cases, also done Operational Reviews for clients as part of their evaluation of prospective plan administrators.