{"id":10247,"date":"2024-08-07T11:00:51","date_gmt":"2024-08-07T16:00:51","guid":{"rendered":"https:\/\/www.bbrown.com\/?post_type=insight&p=10247"},"modified":"2024-08-08T09:46:17","modified_gmt":"2024-08-08T14:46:17","slug":"the-importance-of-claim-audits","status":"publish","type":"insight","link":"https:\/\/www.bbrown.com\/us\/insight\/the-importance-of-claim-audits\/","title":{"rendered":"The Importance of Claim Audits | ERISA, Health Plans and Employer Responsibilities"},"content":{"rendered":"

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Employee Benefits<\/p>\n

\n The Importance of Claim Audits | ERISA, Health Plans and Employer Responsibilities\n <\/h1>\n\t\n <\/div>\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t<\/div>\n\n\t\n[\/vc_column][\/vc_row][vc_row][vc_column width=”2\/3″]\n
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\n The Importance of Claim Audits | ERISA, Health Plans and Employer Responsibilities\n <\/h1>\n\t\n <\/div>[vc_column_text]<\/p>\n

Overview<\/h3>\n

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that imposes responsibilities on fiduciaries of self-funded employee health and welfare benefit plans, including group medical, dental and pharmacy plans. In most cases, the employer sponsoring the plan is a plan fiduciary.<\/p>\n

When a fiduciary selects a third-party administrator (TPA) to administer medical or dental benefits or a pharmacy benefit manager (PBM) to process prescription claims, ERISA requires the fiduciary to:<\/p>\n

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  1. Select and monitor the TPA or PBM taking into account its duty of prudence and its duty of loyalty to the plan participants and beneficiaries<\/li>\n
  2. Ensure the plan is being administered in accordance with the written plan document<\/li>\n
  3. Pay only reasonable plan expenses<\/li>\n<\/ol>\n

    Why it Matters<\/h3>\n

    Several recent federal lawsuits regarding pharmacy benefit plans have heightened awareness of the responsibilities of the fiduciaries of self-funded plans (often including plan sponsors).<\/p>\n

    Even if an employee benefits plan has been audited by a certified public accountant, the financial audit typically will not include rigorous examination of claim processing operations and procedures. A claim processing operational audit will determine whether benefit payments align with plan documents and assist a plan fiduciary to fulfill some of the fiduciary duties described above.<\/p>\n

    What you can do as a plan fiduciary to help improve ERISA compliance:<\/p>\n