Forensic services
Examining the evidence inside an employer health plan.
Who it serves
Employers, attorneys and benefit professionals.
Forensic review applies the same discipline to a health plan that an examiner applies to any body of evidence: collect the records, test them against each other, and describe what they show. F. Randall Childers, Jr. is a Certified Forensic Consultant and Diplomate of the American Board of Forensic Examiners, and has previously served companies and attorneys as a consulting expert and expert witness.
Where a matter requires it, specialists such as actuaries, attorneys, accountants and specialized auditing firms may be brought in. Their involvement is determined matter by matter.
Scope of review
What is examined
Exhibit A
Plan documents & experience
- Current plan documents
- Claims and experience for the past three years and the current year
Exhibit B
Vendor contracts & administration
- Vendor contracts and agreements
- Third-party administrator (TPA) and administrative services only (ASO) arrangements
- In-house versus contracted COBRA administration
Exhibit C
Care management
- Utilization review and precertification
- Case management and disease management
- Nurse lines, peer review and reporting
Exhibit D
Networks & claims
- Network aggregators
- Participating and nonparticipating providers
- Claims negotiations
- Preferred provider organization (PPO) selection
Exhibit E
Pharmacy & stop-loss
- Pharmacy discounts and rebates
- Stop-loss carriers
Exhibit F
Compensation & fees
- Disclosed and undisclosed compensation
- Direct and indirect fees
- Validation against disclosures
Fully insured vs. self-funded
Two spreadsheet totals are not the same kind of number.
A fully insured premium is a fixed cost. A self-funded projection carries a range of exposure up to a maximum. Comparisons should distinguish fixed from maximum exposure rather than treating the two totals as equivalent.
Method
- 01
Gather the facts objectively
- 02
Validate the information
- 03
Diagnose the plan structure
- 04
Report the findings in writing
Forensic consulting reports facts and analysis. It is not legal advice, and no particular finding, savings amount or outcome is promised. The method is described at length in Medical Plan Forensics: Examining the Evidence.
See the booksDiscuss the scope of a review.
Speak directly with F. Randall Childers, Jr. No forms, no call center.