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Partially Self-Funded Healthcare Claim Audit

CTI has the most thorough and vigorous claim audit approach in the healthcare insurance industry. Our innovative proprietary technology and systems provide self-funded health plans with the information needed to measure and improve your claim administration.

Historically, our audit products and services have been tailored for large self-funded clients. Now, however, many small to mid-sized plans that were once fully-insured are seeking the benefits of becoming partially or fully self-funded. This trend toward self-funded insurance is something that needs continual monitoring – especially for partially self-funded plans that have a need for reinsurance.

In response, CTI has developed a scalable healthcare claim audit solution for ALL of our clients…regardless of plan size or budget. You get the same benefits from the same industry-leading team and proprietary cutting-edge auditing software. And because CTI’s audit staff has an average 26 years of healthcare industry experience, we know which rocks to turn over. We know where to look for leaks and how to prevent them from recurring.

When you choose a CTI healthcare claim audit, your organization will be able to:

  • Identify your most significant leaks and recovery opportunities
  • Pinpoint the causes of the problems identified
  • Prioritize your administrator’s attention on what they need to do to enhance performance
  • Verify the ongoing results of remedial actions taken
  • Assure compliance with both federal and plan fiduciary requirements

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Audit Services

A CTI audit will allow you to ensure the fiscal well-being of your organization. Whether you need to answer to your board of trustees or your bottom line, we offer the following partially self-funded audit services:

Due Diligence/Compliance Audit

CTI’s due diligence/compliance audit includes a 100% electronic review with targeted samples, HIPAA compliance review, plan document review, reinsurance review, and our basic suite of data analytics. Deliverables include a specific findings report and a separate work papers document. We perform due diligence/compliance audits for:

  • Medical
  • Dental

Financial Analysis Audit

Our Financial Analysis Audit includes a review of your current contract with your pharmacy benefit manager as well as a quantitative rate comparison with thorough forensic analysis. Deliverables include an executive summary and specific findings report.

Industry Standard Audit

Get the same auditor expertise at a budget friendly price. CTI’s industry standard audit includes a statistically valid random sample audit, our operational review, plan document review with benefit matrix, reinsurance review, and our basic suite of data analytics. Deliverables include an executive summary, a specific findings report and a separate work papers document along with a formal presentation of results. We perform industry standard audits for:

  • Medical
  • Dental
  • Vision
  • Behavioral Health

Pricing and Plan Design Audit

Our Pricing and Plan Design Audit includes the verification of contract pricing for Retail, Mail and Specialty drugs as well as a review for compliance with:

  • Copay/Coinsurance
  • Tier assignments
  • Formulary
  • Refill to soon
  • Excluded Drugs
  • Days supply limits
  • Clinical Edits
  • Quantity limits
  • Age limits
  • Gender limits
  • Step Therapies

Deliverables include an executive summary, specific findings report and a formal presentation of results.

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