Public sector health programs rely on contractors to administer health programs on the behalf of the government. The government relies on internal controls and policies of a third-party and place a large budget item under control of a third-party. We audit third-party contractors that administer health programs for the government, which including audits for contract compliance, benefits/formulary compliance, assessments operations and internal controls, assessing rebates and discounts, performing financial reconciliation, and identifying and recovering overpayments. HDMGS conducts audits to ensure and document compliance with government program’s statutes, contractual agreements, and federal and state regulations.

Health Plan Administrators and Pharmacy Benefit Managers
HDMGS audits health plan administrators, claims processors, pharmacy benefit managers (PBM) to determine compliance with contract terms and plan documents, assess accuracy of paid claims and administrative processes, identify control weaknesses, their causes and suggest process enhancement/cost savings prospects. We hold contractors accountable for delivery of contracted services, including recovery of overpayments.

Public sector programs contracting with private sector administrators typically ask the following questions:

• Are they meeting contractual obligations?
• Are they managing benefits to contain costs?
• Are they delivering the “most favored nation” pricing for services, drugs and supplies?
• Are they sharing the proper amount of discount or rebate dollars?
• Do they have an appropriate and effective fraud, waste & abuse compliance program?

Managed Care Organization Audits
Many government programs turn to private sector managed care organizations to deliver health care services. They rely on these entities to have accurate plan administration, appropriate delivery of services, financial reporting and meeting both State and Federal regulations.

HDMGS audits of MCOs are focused on financial records, claims processing, quality assurance, internal controls and eligibility/enrollment. Our review is intended to verify the accuracy of the expenses and costs associated with the program to assure budgetary controls, and the strength of internal controls and processes to adhere to program integrity requirements. Each area of review is included to detect issues that could challenge the program integrity or jeopardize budgetary compliance.