Contract audit checklist
If think about doing an in-house audit of your managed care agreements, here’s a shopping list of information you’ll need, advise experts:
• Complete listing of all patients specifying whether the member is covered by Medicare, Medicaid, or a commercial plan. This list should at a minimum contain each member’s health plan ID number, primary care physician identifier, and the date of enrollment with each primary care physician, notes health care consultant Jonathan W. Pearce, MBA, CPA, a Bala Cynwyd, PA-based health care consultant.
• All claims billed under the risk contract (when claims are used), including information for tracking their accuracy such as member and provider ID numbers, service dates, payment amounts, claim numbers, benefit codes, service or CPT codes, and the care setting.
• Estimates of provider payment rates, the amounts actually paid to providers according to each capitation contract, and current payment rates for enrollees under Medicare HMO contracting.
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