TPA Audit

Whether you are considering a Workers’ Compensation claims audit for COMPLIANCE or for CONFIRMATION, ESM provides comprehensive, cost effective claim file audits. You will receive reports and  recommendations for improving your bottom line that provide actionable cost saving steps to implement with your
Third Party Administrator.

ESM’s experienced and credentialed claim consultants will collaborate with you to establish the criteria to be audited that will satisfy regulatory requirements as well as uncover leaks in expense costs that can reduce your Workers’ Compensation program costs.

 
 
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TPA Audits

TPA audits can be suited to your specific needs. Whether you are accruing to fund older claims or ensuring proper internal TPA practices that reflect your contract agreement, an audit provides peace of mind that your TPA has your best interest in mind.  Each claim is analyzed and checked for financial and payment accuracy, compliance with Workers’ Compensation regulations and appropriate claims management including regular, result driven diaries and appropriate supervision and oversight.

  • Audit to a contract
  • Audit to measure performance guarantees
  • Audit for best practices
  • Audit for reserving accuracy

 

 


ESM's Triage Funnel:

Audit for Closing Projects

ESM has successfully brought Self Insured Groups in revocation and with ongoing member assessments to finalization by directing and collaborating with the TPA to close ALL open claims. We persisted when it was said it couldn’t be done. ESM can assist you with audit and closing projects for your open and unresolved claims.

We start by categorizing claims using our Tirage Funnel. Then we manage each claim individually to closure. We establish goals and objectives for closures and benchmark the results. We get it done!

“Trust, but verify”
— -Ronald Regan

Cost Saving Areas

Cost Saving Areas:

Litigation

  • ESM established panel of defense attorneys for each WCAB venue
    • Selected specific attorneys who we have worked with who are aggressive in resolving complex cases. 
    • Completed litigation protocols and cover letter to the selected law firms to establish expectations and reach agreement on the intended outcomes
    • Ongoing monitoring and management of attorney fees vs. results

 Medicare Set Asides

  • Reviewed MSA fees and established protocols for TPA adjuster regarding requirement of CMS for MSA submission
  • Recommended MSA vendor and negotiated reduced rates

 Utilization Review

  • Created a  pre-certification list of commonly approved early treatment requests and added to TPA’s Special Service Instructions. This resulted in  expediting initial treatment for the injured employees and reduce UR fees

Best Practices

  • ESM reviewed TPA’s best practices and made recommendations to ensure current practices reflected TPA’s proposal/ contract