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Health Benefits Administration Auditing

Course Description

Print-friendly Course Description and Outline

​The rising cost of health care is a top concern for management and many organizations are requesting internal auditors to audit their health benefit plans.

Auditing health benefits administration (HBA) presents all of the challenges found in auditing areas never audited before, along with demands unique to health benefits administration.

From learning how to detect and recover common payment errors and overcharges to improving program administration and oversight, the topics covered in this course will provide the participant with a broad understanding of the risks associated with HBA and the knowledge needed to conduct audits of the health benefit plans. The course covers the complete claim adjudication process and support services, provider reimbursement methods, funding and accounting exposures, evaluating management care plans, misconception of the privacy act, and much more.

Course Duration: 2 day(s)
CPE Hours Available: 16
Knowledge Level: Basic
Field of Study: Auditing
Prerequisites: 
​None
Advance Preparation: 
​None
Delivery Format: On-site Training (Group-Live)

​Introduction to HBA Auditing

  • Factors impacting rising healthcare cost
  • Common audit findings
  • Who are the players?
  • Approaches in providing coverage

Scope of HBA Audits

  • How to evaluate contractor performance
  • Recommended scope of HBA audit
  • Common contracting issues and assessment
  • Case study — Examination of a significant dollar recovery audit

Conducting the HBA Audit

  • Pre-audit planning and review
  • Records and other information requests for the audit
  • Developing HBA risk assessment
  • Right-to-audit, cost, and other significant matters

Claim Adjudication and Review Processes

  • The process — from claim submission to payment
  • Departments and functions of a claim administrator
  • How to use the computer to effectively audit the claims universe
  • How to audit medical claims

Provider Reimbursement, Funding, and Administrative Fees

  • Provider reimbursement methods
  • Why accounts don’t reconcile
  • How to perform a funding reconciliation
  • Administrative fees assessment

Areas Meriting Special Attention

  • Assessing performance guarantees
  • Special service areas
  • Other group coverage and Medicare
  • Fraud and abuse in HBA

Identifying and Developing Audit Issues

  • Elements in HBA audit findings.
  • Identifying the real audit issues
  • Developing recommendations for improvement
  • Case study — Evaluating an HBA audit

Long-term Planning and Recommendations

  • Commitments for cost controls
  • The team approach to controlling costs
  • Long-term HBA audit planning
  • Recommendations for cost control

Audit Consideration for Specific Program Exposures

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Point-of-Service plans (POS)
  • Prescription drug programs

​Most courses can be delivered through on-site training. You might be surprised that the organization leading the profession is just as committed to the delivery of affordable training.

Contact us by calling +1-407-937-1388 or send an e-mail to GetTraining@theiia.org.