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Health Plan Monitoring and Corrective Action Plans


State departments of insurance and departments of managed healthcare have retained BRG experts to serve as interim officers and monitors for financially troubled managed health plans. BRG experts have assisted the plans with assessing operations and preparing corrective action plans (CAPs) to reach and maintain compliance with regulatory net equity requirements.

During the course of these engagements, our experts have identified revenue enhancement and cost-reduction opportunities through:

  • Identifying deviations from industry financial benchmarks, and researching the reasons for deviation
  • Assessing administrative expenditures through reviewing contracts, letters of agreements, and memorandums of understanding
  • Reviewing incurred but not reported (IBNR) reserves and the reserving process, and recalculating reserves, if appropriate
  • Reviewing risk pool and incentive agreements, including settlements under those agreements
  • Monitoring claims payment process and readjudicating claims samples to evaluate processing and payment accuracy
  • Assessing medical expenditures (inpatient, outpatient, emergency room, and out of network), and identifying outliers
  • Reviewing preauthorization, utilization management, case management, and disease management program policies, procedures, and protocols
  • Evaluating and monitoring the performance of management

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