Health Benefits Administration


Instructor:  Richard M. Stohl

Audit & Control of Health Benefits Administration

This two-day course provides practical approaches for auditors, benefits personnel and others responsible for auditing and controlling health benefits costs.  Topics are addressed from the perspective of the purchaser of the benefits, rather than the insurer or administrator. 

Introduction to Health Benefits Administration

  • Risks and exposures
  • Common misconceptions and beliefs
  • Objectives in conflict
  • Ten costly mistakes
  • Requirements for controlling financial exposures

Program Administration

  • Activities relating to HBA
  • Ten questions you should ask
  • Managed care concepts
  • Recommended management reporting
  • Ingredients for effective stewardship

A Practical Role for Auditors

  • Limitations of traditional audit methodology
  • Common audit findings in HBA
  • Recommended scope of audit
  • Computer testing for overpayment
  • Developing risk assessments
  • Auditing in a managed care environment

Fraud and Abuse in Health Benefits Administration

  • Impact on your organization's costs
  • Common fraud and abuse in HBA
  • Recognizing and responding to fraud
  • Administrator's role and responsibilities
  • Developing fraud control in HBA

Understanding the Claims Process

  • What can go wrong
  • Claim processing and review procedures
  • Claim adjudication systems
  • Claim processing controls
  • How to perform a claims review

The Financial and Accounting Maze

  • Why accounts don't reconcile
  • Control implications of check and draft systems
  • Payment mechanisms and provider reimbursement
  • Exposures associated with void and refund transactions
  • Monitoring cost containment savings
  • Developing financial controls

Administrative Fees, Service Agreements and Performance Guarantees

  • Examining administrative fees
  • Avoidable administrative costs
  • Problems encountered in contracting
  • Essential elements in service agreements
  • Pitfalls of performance guarantees
  • Penalty vs. incentive contracting

Specific Program Exposures

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Point-of-Service (POS)
  • Prescription drug programs
  • Flexible spending accounts
  • Coordination of Benefits
  • Other external vendors

Building for a Long-term Commitment to Cost Controls


  • Glossary
  • HBA Audit Program
  • Medical Claims Audit Program

How to Audit Health Benefits Administration

Rising health care costs are a source of concern for management and auditors in industry and government.  Health benefits costs include not only payments to providers for the cost of services provided; but also the cost of administration, payment errors, overcharges, and fraud and abuse. Health benefits administration is complicated and technical.  The very nature of the industry and reliance on third-party administrators (TPAs) creates opportunity for payment error and overcharges.  Some auditors are learning how to effectively audit health benefits administration for their organizations.  They are recovering such overcharges and identifying opportunities for future cost savings.

How to Audit Health Benefits Administration provides practical approaches for auditors and others.  This one-day seminar covers the "must do's" in health benefit administration auditing.

Seminar topics include:

  • Barriers to auditing health benefits administration
  • Risks and exposures in health benefit administration
  • Common audit findings
  • How to use the computer to audit health benefit claims
  • Auditing in the managed care environment
  • Cost recovery opportunities
  • Fraud and abuse
  • Health Benefits Administration audit program
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