DEA PROCESS OVERVIEW

While there are many outsourcing firms that want to perform your audit for a fee, we at Maggio Solutions believe that this should be a process in your company HR Tool Chest. This will let you maintain eligibility compliance year after year. If you are a Third Party Administrator, you will have this as a new service offering for your existing or potential new clients. The actual process is not exceptionally complex and with our Dependent Eligibility Auditor software and process, it is possible for companies of all sizes to do the audit themselves or for TPAs to audit multiple clients simultaneously.

The standard process consists of five phases as shown in the figure below. While this is what most audit firms utilize, Maggio Solutions Dependent Eligibility Auditor permits a number of customizations and variations. Some variations are suited for completing an audit in less time with low cost. Other variations result in audits that achieve 100% verification, audits which let ineligibles off consequence-free, and audits that enable you to identify all subscribers who knowingly "gamed the system" so you can recapture past claims.
Later in this discussion, we will talk about how you can combine these options to best match your objectives. While the overall time to perform the audit can depend on several factors, most companies can complete a full audit in two to three months. While larger companies can also complete an audit in this amount of time, many may choose to divide the audit by regions, divisions, or random percentage of employees to level the work load. The time component can be even lower if you wish to implement a random partial audit as Phase 1 and follow–up next year with Phase 2 or 3. Phasing provides a method to implement a load–leveled plan that you can support with your available staff and resources. A final option for reducing either the workload or the time–span of the audit is to outsource the labor-intensive portion of the audit to one of Maggio Solutions' approved HIPAA-compliant Benefits Administrators or to your own (if you have one). We have a network of TPAs using our methods and software that can assist you. The licensing of this process includes Maggio Solutions' consultation to develop the perfect plan for your company. The important thing is to begin saving today, while also creating a cultural awareness of the importance of eligibility in keeping medical cost affordable to the company as well as for the employees. The basic steps are illustrated below:

Planning & Employee Buy-In Phase

The first phase addresses the development of a customized audit plan design, pre-audit communications, set-up support processes and training. Detailed process plans for each phase and task are available. Experience has shown that while some fraud may exist, most errors are due to misunderstandings, subject complexity, and unawareness of the criteria. The tempo of the process should be to educate, document, and make corrections. Maintaining good employee relations is paramount.

Amnesty Phase

During the Amnesty Phase, a “no–consequences” disenrollment packet will be mailed. Also during this phase the "New-Hire and Change Request process" is modified to require documentation matching that of the audit. This Amnesty packet will contain details of the upcoming Document Verification and the specific documents that will be required for each dependent category. A "Statement of Consequences" is also included for those who do not take advantage of the Amnesty Phase but are later found to have ineligible dependents. The final component is an Amnesty Affidavit which is a single page form where subscribers have an opportunity to voluntarily disenroll ineligible dependents before the Document Verification Phase begins.

Verification Phase

The Verification Phase is where 80% of the work is completed. This generally last four weeks and during this time all subscribers are to submit the required documentation for each dependent claimed by the subscriber. Submittals are a combination of documentation proving the relationship as well as the financial responsibility. As an example, a marriage certificate is not enough. Proof is required to show the marriage is still intact. This is where the Dependent Eligibility Auditor software is critical. It manages all document submittals, requests for additional information, open action items, appeal requests, and a variety of critical tasks. It also schedules the tasks of the review team and documents and verifies each decision made, each letter written, every comment, and everything else.

Closure Phase

The Closure Phase ties up all the loose ends. At this time, there are subscribers who did not return any requested documentation, others who were slow in responding such that the audit could not be completed by the planned end date, and others who have legitimate exceptions. This is sorted out and the audit concluded. The final step is to produce a full archive report of the total audit.

Multi-Year Eligibility Compliance- Planning for Next Year

The important thing to remember is performing an audit only ensures compliance at that moment. This is why it is important for a company to have an internal eligibility verification process that they can use to maintain compliance year-after-year. For TPAs it is important to have this multi-year verification process available for their clients and new prospective clients.

Software Support Tools

Maggio Solutions offers software tools that will help you implement the process, reduce staffing requirements, and ensure that all documents are managed properly and all action items resolved. The software also provides a complete archive log of every interaction with each subscriber and a scanned image of every document for future reference. Our Dependent Eligibility Auditor Software runs on your computer system.

Implementation Options

The Dependent Eligibility Auditor software and process enables a wide variety of implementation. These including, 1) combination of the Amnesty and Verification Phases, 2) elimination of the Amnesty Phase, 3) dividing a large audit into groups to distribute the workload to balance with staffing resources, 4) rolling continuous audits, or 5) partial random audits. These are all discussed during the Dependent Eligibility Verification Process Planning phase. If you would like to learn more about the Maggio Solutions Dependent Eligibility Verification Process, we have free, private executive level webinars to discuss how this can be implemented in your company, TPA or Brokerage.

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