Page 1 of 6
Health Plan Risk Assessment
Answer 7 questions to assess your visibility into financial leakage, vendor performance, and fiduciary risk across your health plan. You'll receive your Health Plan Risk Assessment upon completion.
How comprehensively can your team independently verify that claims are paid accurately and according to your plan documents, contracts, and pricing terms?
*
A
Continuously across 100% of claims with dedicated personnel and resources to oversee the process
B
We independently review claims periodically or on a limited basis (e.g. sample based audit every 1-2 years)
C
We primarily rely on our TPA/carrier
How much visibility does your team have into where financial leakage is occurring and the extent to which it is putting plan assets at risk?
*
A
Full visibility; we get all of our claims data and consistently mine it for financial leakage
B
Some visibility, but findings are mostly based on utilization trends and traditional data warehouse reporting
C
I don’t feel like we have good visibility into where financial leakage may be occurring
When issues or savings opportunities are identified, does your team have the capacity and specialized expertise to implement changes and monitor the results?
*
A
Yes, with dedicated personnel and specialized expertise to continuously manage the process end-to-end
B
It depends on the issue and available expertise or resources
C
No, limited capacity or expertise often prevents effective follow-through
Is your team able to proactively identify emerging cost and utilization trends before they materially impact plan spend?
*
A
We routinely identify emerging trends before they happen, helping steer strategy and decisions early to avoid unnecessary plan waste, with dedicated personnel and resources
B
We typically identify trends only after they have clearly emerged, leading to reactive decisions and stressed resources to implement them
C
We primarily learn about emerging trends through industry conferences, surveys, and other external sources
How effectively can your team independently monitor vendors and point solutions to verify they are performing as expected?
*
A
Very effectively, with dedicated personnel continuously evaluating their fees and performance against defined standards
B
We independently evaluate vendors, but only periodically or in selected instances
C
We primarily rely on vendor-reported performance and fees to determine their effectiveness and do not independently validate all findings
How confident are you that your health plan's costs and performance are competitive with relevant peers and top-performing organizations?
*
A
Very confident, based on regular, apples-to-apples benchmarking
B
Somewhat confident, but our benchmarking is limited in scope or comparability
C
Not very confident, with limited visibility into how our plan compares
How confident are you that your team can demonstrate effective oversight of your health plan in accordance with its ERISA fiduciary responsibilities?
*
A
Very confident, with dedicated resources, documented processes, and supporting data and evidence
B
Somewhat confident, but our documentation or oversight has gaps
C
Not very confident, with meaningful gaps in our ability to demonstrate effective oversight
Next
