Self-Insured Health Plan Advisory Services
Self-insured health plans present opportunities for cost savings and customization, but they also demand that plan sponsors shoulder increased responsibilities, necessitating expertise in various domains. These encompass financial management, vendor oversight, regulatory compliance, cost control, and data security.
Self-Insured Health Plans – How We Help
Our team of health plan advisors have worked with plan sponsors from medium to jumbo health plans for more than 3 decades to help them address these responsibilities through a comprehensive suite of services and technology designed to mitigate operational and compliance risk. This includes everything from Fiduciary Oversight of plan Sponsor’s health plan, claims audits, to cyber risk assessments.
Types of Plans We Evaluate
- Medical
- Mental Health
- Prescription Drug
- Dental
- Vision
- Disability
- Health FSA
- Other Ancillary Plans
Key Health Plan Sponsors Advisory Service Offerings
Medical claims audits (also called healthcare claims audit, insurance claims audit, third party administrator (TPA) audit, and more) play a crucial role in the monitoring and oversight of 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. Medical claims audits are typically conducted to assess the administration of various types of benefits, including medical, pharmacy, dental, vision, and disability benefits.
Risk Assessments identify potential vulnerabilities, gaps, and areas of exposure within administrative processes and systems, enabling healthcare plan sponsors to proactively manage risks, implement effective controls, and safeguard 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 contractual agreements between the healthcare plan and the service provider to ensure adherence to specified terms, conditions, and regulatory requirements. The goal of the audit is to verify that both parties are fulfilling their contractual obligations, identify any areas of non-compliance or discrepancies, and mitigate risks associated with contract performance.
Learn more Compliance Audit of Contract Terms with a TPA or PBM
Assesses the procedures and practices used to determine the eligibility of individuals for coverage under the plan. This review typically examines the enrollment process, documentation requirements, verification methods, and decision-making criteria to ensure that individuals are accurately assessed for eligibility based on the plan’s eligibility criteria and regulatory requirements.
Learn more about Eligibility Process Review
Additional Advisory Services
We leverage technology, data analytics and digital solutions to provide actionable insights to our clients for better 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
Success Stories: How Our Services Helped 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 MoreFeatured Insights
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As a plan sponsor, keeping up to date with the various service offerings that exist can be challenging, let alone knowing which are most applicable. This guide offers a concise […]
Optimizing Health Plan Management: The Crucial Role of Comprehensive Board Reporting
Effectively managing a health plan demands a constant flow of accurate, timely, and relevant data to the plan sponsor and its board. Integration of financial and non-financial data is key […]
Enhancing Claims Processing Oversight: Key Aspects of User Entity Controls
In the context of claims processing for self-insured plans, Third Party Administrators (TPAs) play a critical role in designing internal controls to ensure accuracy and timeliness. However, relying solely on […]
Client 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
Contact Us
For more information or to discuss your business needs, contact Withum’s Self-Insured Health Plan Advisory Services Team.
