Medical and Prescription Insurance Audit Professional Services

The Vendor is required to provide medical and prescription insurance audit professional services.
- Third-party administrators necessary to provide coverage to State employees and non-Medicare and Medicare retirees, enters into contracts for the purpose of general administration of employee benefits, determines if/whether contracts are to be fully insured or self-insured, and adopts rules and regulations for the general administration of the employee benefit coverage.
- Benefit eligible plan participants include the State’s active employees (State agency, school district, charter school, State University, and Technical Community College employees) and their dependents; non-Medicare and Medicare retired employees and their dependents; employees of non-State groups (i.e., towns, fire companies, the University of Delaware; this group is also referred to as “participating group” or “non-payroll group” employees) and their dependents; and COBRA participants.
- Vendors may bid on either audit service or both (i.e., medical insurance contract compliance audits and/or prescription drug insurance contract compliance audits, or both); as noted above, proposals for medical insurance contract compliance audits that include proposed audit services for the surgery plus program should provide pricing for that program separate from the pricing provided for audits of state.
- The committee is interested in receiving proposals from organizations who’s medical and prescription drug claim audit services focus on retrospective reviews of plan experience, which is consistent with the audit services that the committee is receiving from its incumbent contract compliance auditor.
- The selected organization(s) shall be required to provide the following services, at a minimum:
• Offer state of the art administrative services for contract compliance audits that occur either in real-time on an ongoing basis or retrospectively;
• Provide excellent account management services to the Office including timely reporting and support with addressing audit findings with the carriers;
• Have a strong reputation and historical experience in the contract compliance audits conducted either in real-time on an ongoing basis or retrospectively;
• Have strong capabilities to proactively identify and recover overpaid claims;
• Provide a competitive financial proposal;
• Provide performance guarantees; and
• Be responsive to changes in the program and requests of the committee and the office.