Specifications include, but are not limited to: A. Account Management i. Assign a dedicated (but not necessarily exclusive) Account Manager, who will act as the Board primary contact for activities relative to all aspects of the Contract between the Board and the Auditor, who must have a minimum of five (5) years’ experience conducting and supervising independent medical claims and performance audit services to self-insured health plans consisting of at least 100,000 covered lives, who shall be classified, at a minimum, as a senior auditor level, and who will supervise all aspects of the resulting contract with the Board;. ii. Provide all services directly related to this Contract from an office located within the United States. iii. Perform all services provided in the Contract between the Contractor and MDFA in accordance with customary and reasonable industry standards as well as in strict conformance to all laws, statutes, and ordinances and the applicable rules, regulations, methods and procedures of all government boards, bureaus, offices, and other agents. The Contractor shall be responsible for the complete performance of all work; for the methods, means, and equipment used; and for furnishing all materials, tools, apparatus, and property of every description used in connection therewith. No statement within this Contract shall negate compliance with any applicable governing regulation. The absence of detail specifications or the omission of detail description shall be recognized as meaning that only the best commercial practices are to prevail, and that only first quality materials and workmanship are to be used. B. Medical Claims and Performance Audit Services i. At the request of the Board, at least annually perform a comprehensive and objective medical claims and performance audit of the Plan’s medical claims third party administrator to determine if the medical claims were adjudicated according to appropriate Plan benefits, the contractual standards, industry standards, and State and federal regulations. The medical claims and performance audit must be based on a statistically valid stratified random sample that achieves a minimum 95% confidence level +/-3% and must include at a minimum the results for the following key performance indicators: financial accuracy, payment accuracy, processing accuracy, and claims processing turnaround time. The audit must include a review of the medical claims processed by the medical claims third party administrator, including readjudicating medical claims to evaluate the administrator’s processes and systems relating to such areas as: eligibility, coding, pricing (including proper application of allowable charge and discount arrangements), deductible accumulators, identification of duplicate bills, application of Plan benefits, COB, subrogation, medical necessity, ineligible/eligible charges, compliance with the Plan Document, timeliness of processing, interaction with other vendors, and file documentation. ii. In addition to the statistically valid random sample audit, will conduct an electronic screening of 100% of the medical claims processed, with targeted sample analysis to target and test known administrative issues and identify process improvements and cost recovery opportunities. The Auditor will screen medical claims with material errors in a wide variety of high-risk categories and apply unique and proprietary error codes when potential errors are found. The categories may include, but are not limited to: a. Medical Claims Payment and Pricing b. Duplicate payments to providers and/or employees c. Provider discounts and fees d. Coordination of benefits e. Plan limitations and exclusions f. Multiple surgical procedures g. Large claim review and case management h. Denial of mandated benefits i. Workers’ Compensation j. Subrogation/right of recovery from third parties k. Fraud, Waste and Abuse Review
