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Health & Welfare Consulting and Audit Services

Team Meeting

 "The cost of healthcare services is expected to rise 7.5 percent in 2013, more than three times the projected rates for inflation and economic growth, according to an industry research report released..." (Reuters)

At DMA we understand that uncertain times require creative solutions.  The 2010 Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act or Health Care Reform, has given rise to a new set of challenges within the healthcare industry that directly impact employers.  DMA's combined 200 years of industry knowledge provides the necessary tools for DMA to address these challenges through a variety of creative solutions and products, and provide proactive guidance to employers in addressing the challenges and opportunities of Health Care Reform.

DMA's consulting services appeal to a wide range of employers throughout the United States, including private and public companies, non-profit organizations, self-funded employers, fully-insured plans, multiemployer plan trusts, third party administrators, and other consultants.

What sets DMA apart from other consulting firms is that we bring a clinical team with medical experience to the table to provide employers with a clear understanding of their claims and plan benefit utilization reports.  In addition to performing an in-depth financial analysis, DMA's staff of registered nurses drill into your claims and utilization data and analyze the medical cost drivers that impact your benefits.  We use the following four-step process to focus on the cost drivers and address the issues identified:

Analyze Data → Identify Problems Create Solutions Implement Change

Health & Welfare Consulting Services include:

  • Development of strategic planning document
  • Specialized Plan design
  • Funding projections and Modeling
  • Contract design and negotiation for Administrative Services Agreement (ASA)
  • Contract design and negotiations for Pharmacy Benefit Manager (PBM)
  • Carrier renewal analysis and negotiation
  • Stop-loss Insurance negotiations
  • IBNR calculations
  • Design and issue RFPs or RFIs, including negotiations and implementation oversight
  • Financial analysis and reporting
  • Compliance Services (PPACA, ERISA, HIPAA, FMLA, 5500s)
  • Large claims analysis
  • Trend analysis
  • Provider discount evaluation
  • Provider disruption analysis
  • Wellness Program development
  • Open enrollment services

Audit/Consulting Services:

Part of DMA's consulting solution for Self-Funded plans is to conduct 100% annual audits of medical and prescription paid claims.  DMA audits are designed to ensure that carriers are utilizing industry standard practices in their respective area of claims administration, and to identify opportunities to improve processes and prevent future errors.  DMA conducts audits in the following areas:

  • Medical
  • Dental
  • Pharmacy (Pharmacy Benefit Manager (PBM))
  • Eligibility
  • Dependent Eligibility
  • Claim Audits for Processing Accuracy
    • DMA reviews 100% of paid claims using a combination of electronic analysis and expert clinical review to identify incorrectly processed claims. 
  • Eligibility Audit
    • DMA performs an electronic comparison of the employer’s human resource/payroll/TPA system information to the respective health carrier eligibility and claim information to identify gaps in eligibility information that can result in retrospective recovery and future claim costs savings.

DMA's audit services include providing the following:

  • A written report of findings and a complete inventory of recoverable claims
  • Written recommendations to improve carrier/TPA efficiency and lower medical claims costs going forward
  • Pursuing collection of identified overpayments on behalf of employer