Health Benefits Administration


Instructor:  Richard M. Stohl

Audit & Control of Health Benefits Administration

This two-day course provides practical approaches for auditors, benefits personnel and others responsible for auditing and controlling health benefits costs.  Topics are addressed from the perspective of the purchaser of the benefits, rather than the insurer or administrator. 

Introduction to Health Benefits Administration

  • Risks and exposures
  • Common misconceptions and beliefs
  • Objectives in conflict
  • Ten costly mistakes
  • Requirements for controlling financial exposures

Program Administration

  • Activities relating to HBA
  • Ten questions you should ask
  • Managed care concepts
  • Recommended management reporting
  • Ingredients for effective stewardship

A Practical Role for Auditors

  • Limitations of traditional audit methodology
  • Common audit findings in HBA
  • Recommended scope of audit
  • Computer testing for overpayment
  • Developing risk assessments
  • Auditing in a managed care environment

Fraud and Abuse in Health Benefits Administration

  • Impact on your organization's costs
  • Common fraud and abuse in HBA
  • Recognizing and responding to fraud
  • Administrator's role and responsibilities
  • Developing fraud control in HBA

Understanding the Claims Process

  • What can go wrong
  • Claim processing and review procedures
  • Claim adjudication systems
  • Claim processing controls
  • How to perform a claims review

The Financial and Accounting Maze

  • Why accounts don't reconcile
  • Control implications of check and draft systems
  • Payment mechanisms and provider reimbursement
  • Exposures associated with void and refund transactions
  • Monitoring cost containment savings
  • Developing financial controls

Administrative Fees, Service Agreements and Performance Guarantees

  • Examining administrative fees
  • Avoidable administrative costs
  • Problems encountered in contracting
  • Essential elements in service agreements
  • Pitfalls of performance guarantees
  • Penalty vs. incentive contracting

Specific Program Exposures

  • Health Maintenance Organizations (HMO)
  • Preferred Provider Organizations (PPO)
  • Point-of-Service (POS)
  • Prescription drug programs
  • Flexible spending accounts
  • Coordination of Benefits
  • Other external vendors

Building for a Long-term Commitment to Cost Controls


  • Glossary
  • HBA Audit Program
  • Medical Claims Audit Program

Health Benefits Administration: Assessing Risk Related to Health Benefits Cost 

Learn How to Perform a Risk Assessment and Evaluate Internal Controls within Your Organization to Control Health Benefits Cost.

The high cost of inefficiency, provider overcharges, payment errors, and fraud and abuse in health benefits warrants more than casual oversight of the program's administration.  Assisting in the control of health benefits cost has become an extremely high profile area where internal auditors can enhance their image as a value-added service to their organization.

Internal auditors can achieve cost savings, recover overcharges, and minimize financial exposures by familiarizing themselves with methods of controlling health benefits costs.  This one-day seminar looks at the risks and exposures in health benefits administration and the how and why things can go wrong.  The seminar covers how to evaluate controls over program administration oversight and develop risk assessments of the exposure areas in health benefits administration.

 Seminar topics include:

  • Internal Audit's involvement in controlling health benefits cost
  • Common misconceptions and beliefs
  • Understanding the "Privacy Act"
  • Risk and exposures in health benefits administration
  • Risk assessment of your organization's internal processes
  • Evaluating the Administrative Services Agreement (ASO)
  • Recommended internal controls over program stewardship
  • Ten ways internal auditors can help control health benefits cost
  • Health Benefits Administration audit program
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