Scope of examination
What we examine
Our examination is financial and fiduciary. We read the contracts, follow the money, and establish what each party was entitled to receive.
Medical claims
Claim-level review of what was billed, what was allowed, what was paid, and on what contractual basis. Duplicate, ineligible and unsupported payments are identified by evidence, not estimate.
Pharmacy expenditures
Pricing definitions, rebate flow, spread, formulary decisions and specialty drug arrangements, read against the actual contract language rather than the summary presented to the plan.
Stop-loss arrangements
Attachment points, lasering, contract basis, disclosure obligations, reimbursement history and the treatment of large claims.
Broker and vendor compensation
All direct and indirect compensation: commissions, overrides, bonuses, contingent payments, service fees and undisclosed revenue from third parties.
Administrative contracts
Administrative service agreements, performance guarantees, audit rights, data access rights, termination terms and the obligations each party actually accepted.
Provider pricing
Facility and professional pricing, reimbursement methodology, and whether amounts paid correspond to the terms in force at the time of service.
Network arrangements
Network access fees, repricing, out-of-network handling, and the relationship between the network, the administrator and the plan.
Ancillary benefits
Dental, vision, disability, life, and point-solution vendors: their contracts, their compensation, their measurable contribution.
Fiduciary governance
Who holds fiduciary responsibility, how decisions are made and recorded, and whether the plan meets its obligations under U.S. law.
Plan documentation
Plan documents, summaries, amendments and disclosures reviewed for internal consistency and for consistency with how the plan is actually administered.
A note on method
We do not calculate savings against inflated charges. We establish what the legitimate cost should be, and whether the amount paid can be defended.