An audit finding that waits for the renewal becomes next year’s cost.
When a claims or pharmacy audit turns up a pattern, the easy response is a note in the renewal file. We take the finding to the vendor while the contract still has leverage in it: correction, recovery where the contract allows it, and a change that stops the pattern repeating.
A pattern is different from an error, and it needs a different response.
One mispaid claim gets reprocessed. A pattern means a system setting, a pricing table or a payment rule is wrong, and it will keep producing the same result until someone changes it.
Confirm the Pattern
We test each finding against the plan document and the contract before we present it, because a vendor’s first move is to argue the plan language allowed it. A finding that survives that argument is one the vendor has to answer.
Size It
We quantify how many claims and dollars the pattern touched across the audit period, since a specific number is what moves the conversation from apology to remedy. Sizing a vendor error pattern is the first step in holding a claims administrator accountable.
Ask for the Root Cause
We want to know which setting or rule produced the result and when it started, so the fix goes to the cause rather than to the handful of claims someone reprocessed. Root cause analysis is what separates a lasting vendor fix from a one-time reprocessing.
Put a Date on It
Every corrective action gets an owner and a deadline in writing. Without one, a fix becomes a promise the vendor revisits at renewal, which is exactly the outcome we are trying to avoid. Written corrective action plans are the backbone of vendor accountability.
What the contract says decides what you can recover.
Accountability depends on terms signed long before the audit: audit rights, look-back periods, performance guarantees and who bears the cost of errors. We read those terms first, because they set the ceiling on any remedy.
Audit Rights and Look-Back
Many contracts limit how far back an audit can reach and how often it can run. If a pattern began before that window, recovery stops at its edge, which is why we flag a short look-back at the next contract negotiation.
Performance Guarantees
Guarantees on accuracy, turnaround and service often put fees at risk, but only if the plan measures and claims them. We track them against the vendor’s own reports so a missed guarantee becomes a credit, not a footnote. Performance guarantees only pay when someone claims them.
Recovery Mechanics
An overpayment to a provider is usually recovered from that provider, which can take months. We push for a credit or offset where the contract allows it, so the plan is not waiting on recoveries the vendor has little reason to chase.
The real test is whether the pattern is gone next year.
A vendor that corrects the claims we found but not the setting behind them will reproduce the problem. So we check.
Re-Test the Fix
After the vendor reports a correction, we review claims processed since then, every record, not a sample, for the same pattern. That confirms the root cause was addressed rather than just the reported examples. Re-testing is the step that makes vendor accountability real.
Carry It Into the Renewal
Unresolved findings and missed guarantees go into the renewal and any request for proposal as terms, so the incumbent’s record is priced into the decision instead of forgotten. A vendor’s audit history is part of its price, and the renewal is where that price gets set.
Know When to Move
Sometimes the answer is a different vendor. We lay out the cost of switching, including implementation, disruption and run-out, next to the cost of staying, so the choice is a decision rather than a reaction. Staying can be right when the vendor has fixed what the audit found.
What employers ask when an audit finds a problem.
Will pressing a vendor damage the relationship?
Handled with evidence, it usually improves it. Vendors respond to clients who read their reports, and a documented, specific finding is easier for them to fix than a general complaint. Specific, documented findings are the basis of a productive vendor relationship.
Is the vendor liable for every error?
That depends on the contract and on whether the error followed plan instructions. Where liability is contested, the question goes to counsel, and we prepare the record they need to answer it. The vendor contract is where liability for claims errors is decided.
Is acting on an audit part of our fiduciary duty?
Monitoring the vendors you hire is part of running a self-funded plan, and acting on audit results is visible evidence that the monitoring happened. Counsel decides how the duty applies to your plan. A documented vendor monitoring process supports the plan sponsor’s oversight.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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