PRISM works with our data management partner to audit the eligibility of all members and / or their dependents in a medical plan. State of the art techniques are used to identify plan members (employees and dependents) who are not eligible for coverage, and remove them from the medical plan, generating a strong return on investment. Enrollment audits can be performed as a one time action or on a periodic basis, at the desire of the client.
Benefits
Ø Completely update difficult to maintain enrollment files.
Ø Eliminate errors, duplications and inconsistencies in enrollments.
Ø Identify the 1% to 5% of employee enrollments that are incorrect, and the 4% to 12% of dependents who do not meet enrollment criteria.
Ø Create potential recovery of claims paid incorrectly due to enrollment errors by combining an Enrollment Audit with a Claim Overpayments Audit.
Ø Reduce potential future claim payments by ensuring enrollment files are accurate.
Ø Determine that enrollment related regulatory requirements, such as Medicare Section 111 Reporting Requirements, are met.
Enrollment Analysis Services
Ø Dependent Audit – Update dependent information and identify dependents who should not be enrolled due to changes in marital status, student status, etc..
Ø Enrollment Audit – Obtain current enrollment information on all employees enrolled in the plan.
Process
Ø File To File Comparisons – Compare enrollment files to internal employee rosters, payroll lists, etc. to identify and assess differences between the two. Identify unknown / missing members and incorrect enrollment information.
Ø Dependent Verification Mailing – A customized letter and questionnaire sent to employees with dependents enrolled to obtain updated information.
Ø Enrollment Verification Mailing – Client specific letter and questionnaire sent to all employees enrolled to obtain updated information.
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