Audit Scope

Our audit includes a review of your health care management program’s descriptions, administrative policies and procedures, technology support, data tracking and reporting, integration, and performance metrics.

We’ll review the quarterly reports and annual reports prepared by your program provider to determine how your results compare against their stated policies and procedures and how they compare against national averages. We’ll also review member-specific information that measures actual execution of the health care management program’s processes. We target members whose care management interventions would have been expected (based on triggers including high dollar/large claimant status, repeat inpatient admissions, frequent emergency department visits, certain high cost diagnosis, and intensive outpatient services).