Dependent Eligibility Verification

DEPENDENT ELIGIBILITY VERIFICATION — A DISCUSSION OF THE USE AND ADVANTAGES OF STATISTICAL PROCESS CONTROLS TO IMPROVE ELIGIBILITY VERIFICATION PROCESSES

As the high cost associated with covering ineligible dependents on employer-sponsored benefit plans has become clear, approaches for attempting to control it have varied widely. Equally varied have been the costs, benefits achieved, problems encountered, and impact on employee relations and employee benefits staffs.

This CTI White Paper discusses issues attendant to the "100% audit" approach commonly being taken to purge ineligible dependents from health plan rolls, and contrasts it with an approach developed by CTI for addressing the issue more effectively through evaluating, improving, and monitoring dependent eligibility enrollment and verification processes. 

CTI's approach first provides a framework for identifying and addressing process weaknesses in the communications and procedures critical to effective dependent eligibility maintenance. Then, using both claims and eligibility data to test for ineligible dependents who have filed claims in a given audit period, our audit and control approach identifies the causes of the weaknesses (rather than just the symptoms) and works to remedy and improve them continuously over time. Identification and removal of ineligible dependents is likewise facilitated through the methods employed.

Self-funded plan sponsors seeking to improve eligibility verification processes to avoid repeat problems will be interested in considering this alternative.