Third Party Administrator Audit Program
(Medical, Dental and Disability)

Introduction
Every day, Third Party Administrators, (TPAs) are receiving large volumes of claims from a variety of healthcare providers. In many cases, errors involving provider contracts, duplicate claims, Coordination of Benefits and a variety of plan design issues slip through the cracks and end up costing self-insured employers significant dollars on their healthcare claims reimbursement. Many factors contribute to this problem, including pressures on the TPA to expedite the processing of claims as well as confusion with coordination of benefits and a variety of other complex reimbursement issues.

Opportunity
In response to this costly national problem, TMDG LLC has developed a unique and comprehensive auditing and consultation approach which focuses on identifying and resolving claim processing and plan design errors. Using the unique experience of our management staff, TMDG 's engagement includes three separate phases: I. Operational Review, II. Statistical Claims Audit, III. 100% Electronic Claims Review. These all lead to better transparency, immediate identification and recovery of overpayments and improvements in plan design to prevent future losses.

I. Operational Review

• Comprehensive pre-operational questionnaire
• Review & evaluation of answers by TMDG Evaluation Specialists
• Answers validated through on-site TPA meetings
• Written evaluation report provided to client

II. Statistical Claims Review

• On-site audit utilizing sampling techniques
• Sample pulled from claims dump provided by TPA
• Each claim selected will go through a rigorous review to verify key criteria
• Written report will be provided and reviewed with client

III. 100% Electronic Claims Review

• Utilizing our proprietary claims software, "The Sentinel®", TMDG will perform a focused review of 100% of claims processed by your TPA.

Audit Process Overview
TMDG's on-site audits go beyond the traditional audit level and include six distinct phases to ensure that all errors are identified and any plan design flaws are contained and corrected.

Step 1 Pre-Audit & Review of TPA Contract
Step 2 Data Request & TPA Questionaire
Step 3 On-site Audit & Operational Review
Step 4 Findings, Report & Recommendations
Step 5 Implementation
Step 6 Concurrent Monitoring

Types of Errors Identified

• Incorrect Provider Contract Rates
• COB Errors
• Duplicate Billings/ Payments
• Incorrect Benefit Coverage
• Termination/ Retro of Member Eligibility
• Subrogation
• Payments to an Incorrect Providers

Client Benefits

• Identification and Recovery of Overpayments
• Plan Design Improvements to Prevent Future Losses
• Full Transparency of TPA Relationship
• Improved TPA Contract Negotiating Capability
• Improved Working Relationship with TPA
• Lower Costs to Enrolled Employees

We at TMDG LLC are dedicated in tailoring our services to meeting each clients individual needs.