SERVICES
Morgan Healthcare Audits (MHA) is much, much more than just an auditing company. Our services extend well beyond that of other auditing companies. We provide insurers or third party administrators with a full arsenal of tools.
The additional services are designed to aid any entity having a fiduciary liability with the means necessary to meet the requirements of the Employee Retirement Income Security Act (ERISA).
Morgan Healthcare Audits performs four types of audits: retrospective, prospective, business practices audit, and the pharmacy audit.
HOW AN AUDIT WORKS
The audit starts with analysis of the Client-PBM contract to determine auditability. Each auditable contract item is then reviewed and determination is made as to whether the data elements needed for auditing have been supplied. If they have, we decide whether the item requires a program module be constructed by IT or if it would be easier for the auditor to perform the calculations.
We will select a team consisting of a programmer, PBM auditor and clerical person. Computer modules are created based on the contract terms for readjudication of all paid claims, claims are extracted into specific groups and the Auditor begins analysis of the data.
In general 2 audits are performed. One is based solely on the contract terms. The second audit, is based on the PBM industry schemes to over bill or inflate the cost to the Client. In general, inappropriately increase the Client’s Rx Spend.
TYPICAL AUDIT TIME ESTIMATES
Once clean data, data definitions, data layouts and contracts with addendums are received, MHA can complete the audit in 8 to 10 weeks at the current time. This estimate can drop or slightly increase based on the number of simultaneous audits being performed.
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