Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-7832

Government Authority located in Washington; USA based organization looking for expert vendor for claims audit third party service.

[*] Budget: Looking for Proposal

[*] Scope of Service:

(1) Vendor needs to provide claims audit third party service.
- Review the past plan year’s (April 1, 2022 – March 31, 2023) total medical claims administration between providers and both of county’s third-party administrators, regence BlueShield and Kaiser Permanente (administrators).
- Provide proposed schedule and work plan.
- Provide the complete methodology for the analytical work to audit third-party agreements using industry standards.
- Review the county’s enrollment records versus administrators eligibility records for the audit period to confirm that only those truly eligible for the plan were covered.
- Review all pertinent plan design documents in order to customize consultants electronic auditing tools.
- Review and evaluate written documentation of claims administration program to ensure proper inclusion of claims filing procedures, internal financial control mechanisms and claim and claim adjustment expense reports.
- Review and evaluate written documentation of the claims appeal procedure to ensure proper inclusion of a time limit for filing an appeal, a time limit for response and a provision for the second level of review.
- Work directly with county’s third-party administrators, for claims information and details for auditing purposes.  
- Perform a stratified, random sample claims audit to test administrator’s medical claim processing performance during the review period. The population of claims will consist of claims incurred and paid within the review period. The population will then be stratified by paid dollar amounts and random selections will be selected within each stratum. With the sample selected, the claim will be tested from submission through reimbursement to determine that the claim was paid correctly.  
- Identify the source of errors and corrective action on the administrator’s part to prevent the errors found from occurring in the future. Produce exception reports identifying and organizing all claims potentially paid in error into error categories.
- Work with administrators on findings. Administrators will be provided copies of all worksheets in order for them to reply to the consultant’s findings. Administrators will then return their responses back to the consultant within a reasonable amount of time and all responses will be published in the final report to the county.
- Provide recommendations to the county for effective administration of the plan to ensure proper claim processing.
(2) All question must be submitted no later than November 01, 2023.
(3) A contract period will be for one year.

[*] Eligibility:

- Onshore (USA Organization Only);

[*] Work Performance:

Performance of the work will be Onsite and Offsite.

Expiry Date : Thursday, 9 November, 2023

Question Answer Deadline : Wednesday, 1 November, 2023

Category : Medical Billing and Coding, Auditing, Finance and Accounting

Country : USA

State : Washington

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