Understanding Gag Clause Prohibition Compliance
The Consolidated Appropriations Act of 2021 (CAA) significantly impacts group health plan fiduciaries by eliminating restrictions on data transparency and requiring fiduciaries to monitor their service providers. The Department of Labor (DOL) mandates that plan sponsors ensure plan resources are used correctly, with failure to uphold fiduciary duties leading to severe penalties. This white paper explores the implications of gag clause prohibitions, the importance of claims audits, and how plan sponsors can comply with these regulations to safeguard their fiduciary responsibilities.
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Over $200k in Mistakes Uncovered by Claims Audit
A Native American Organization with over 9,000 enrolled members engaged BMI to audit and verify the accuracy of medical and prescription drug claims paid their third-party administrator (“TPA”) and pharmacy benefits manager (“PBM”).
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Due Diligence Medical + Pharmacy Claims Audits Reveal Systemic Mistakes
An employer in the manufacturing industry with over 450 employees engaged BMI to audit and verify the accuracy of medical and prescription claims payments. Both the medical and pharmacy claims audits identified errors related to claims processing, including payment for ineligible services and systemic administrative issues. The TPA agreed to overpayment amounts totaling over $70,000 and to run additional impact reports to identify any other claims impacted by the systemic issues uncovered. Follow-up audits are recommended for both areas to monitor progress and minimize financial risk.
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12,500+ Prescriptions Impacted by PBM Mistake
This nationally recognized electronics and technology company engaged BMI to conduct a pharmaceutical audit of their prescription drug plan and pharmacy benefit manager (“PBM”) to ensure claims were being processed correctly.
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Pharmaceutical Audit Reveals over $500,000 in Errors
This major metropolitan hospital engaged BMI to conduct a pharmaceutical audits of their prescription drug plan and pharmacy benefit manager (“PBM”) to ensure claims were being processed correctly.
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Recurring Pharmaceutical Audit Continues to Prove Beneficial
For over 10 years, this large public school district has engaged BMI to conduct annual pharmaceutical audits of their prescription drug plans and pharmacy benefit manager (“PBM”).
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Annual Pharmaceutical Audit Uncovers Systemic Errors
This large county government engages BMI to conduct annual pharmaceutical claims audits of their self-insured pharmaceutical plan and pharmacy benefit manager (PBM). In addition, the client also engaged BMI to conduct a contractual financial guarantee audit.
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Medical & Rx Audit Yields Big Savings for Employer Group
At the recommendation of their consultant following concerns about the accuracy of claims adjudication, this employer group approached BMI to conduct an audit of medical and prescription drug claims paid by their third-party administrator.
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Savings Follow Audit of Client’s Third-Party Administrator
BMI was engaged to audit this manufacturer’s new third-party administrator for both their medical and prescription drug plans to ensure benefits were being paid appropriately and to evaluate overall administrative effectiveness.
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