About us

At Seneca Consulting Group, we believe that "you can't manage what you can't measure." This belief is echoed throughout our approach to benefits consulting. We have pioneered a new process in benefits consulting that we call Audit-Based Consulting.  Audit-Based Consulting leverages uses technology to ensure vendor compliance with service agreements and financial guarantees.  Seneca Consulting Group's Audit-Based Consulting services include the following types of data management and analysis:

  • Comprehensive Medical and Pharmacy Claims Auditing

  • Medical and Pharmacy Claims Data Warehousing

  • Health Plan Modeling and Trend Prediction

Medical and Pharmacy Claims Auditing

Comprehensive claims auditing is the most important step in Audit-Based Consulting. Much like the strong foundation of a house, a comprehensive claims audit is the foundation on which to build a dynamic program to monitor utilization, cost and performance trends.

Unlike other companies that audit and analyze only a sample of claims, Seneca Consulting Group audits 100% of claims, eliminating inaccuracies and errors when making important decisions about a benefits plan or vendor contracts.

Claims and Data Warehousing

Claims auditing for compliance purposes is only part of the story. Because we audit 100% of claims, Seneca Consulting Group has the unique ability to data warehouse claims history for our clients, making the information available for other important applications, such as benefit plan design modeling and care management.
Having claims data readily accessable in a warehouse that uses standard SQL technology makes data integration initiatives easier. And, maintaining historical data smoothes transitions for clients if there is a need to change a third-party administrator or pharmacy benefit manager.

Plan Modeling and Risk Prediction

Seneca Consulting Group's claims data warehouse provides actuaries, and underwriters clean and accurate data to forecast future costs and health care trends. Client's claims data may be exported to any data integration or risk prediction application, and can be used to support implementation of new vendors and additional services that may be desired by our clients in the future.

Health Benefits Auditing

Seneca Consulting Group offers a unique health and welfare auditing package featuring medical and pharmacy claims auditing. Our approach audits 100% of the plan's medical claims and 100% of the health plan's pharmacy claims. The audit process combines the exceptional technology and expertise of two of the industry's leading companies in the health care auditing field.

Seneca Consulting Group

Since our inception in 1997 the Seneca Consulting Group has pioneered pharmacy benefit manager (PBM) audit protocols. Over the years we have refined our methods with the goal of improving transparency for health plan sponsors. Our clients include employers, third party administrators, insurance carriers and health and welfare funds. While our client base may be diverse, our clients share common goals:

  • Understand the cost drivers of their pharmacy benefit plan

  • Validate the financial performance of their PBM vendor

  • Identify and maximize savings opportunities

  • Improve outcomes and the overall health of their members

In 2006, The Seneca Consulting Group recognized the need to add a medical claims auditing component to our service offering. We embarked on the addition of a complete medical claims audit process using the same philosophy that had been successful for us with pharmacy benefit claims.

Pharmacy Benefit Manager Performance Audit

The Seneca Consulting Group's proprietary system is designed to analyze pharmacy claims and help your organization maximize its pharmacy benefit program. Of all the analytical tools in the product suite, the price verification reports are the most compelling.

PBM Service Modes:

RETROSPECTIVE AUDITING - analyzes historical claims as far back as six years. Allows clients to audit past billing and generate reports to show where the health plan was overcharged for claims. These reports may be used to recover damages from your PBM resulting from overpayments and claims payment errors

PROSPECTIVE AUDITING - analyzes current claims and provides results, within minutes of uploading, to verify invoices prior to payment. Prospective auditing services allow plan sponsors to contunually monitor the financial performance and payment accuracy of the PBM vendor. The Seneca Consulting Group will review every claim invoice and determine where you the plan sponsor overpaid. Audit  reports show how much our clients really owe thier PBM so that our clients don't keep overpaying with each invoice. Clients may include the audit reports along with payment for the correct amount.

Audit Process:

We accomplish PBM audits by importing claims history for the period to be audited into our proprietary pharmacy audit and tracking database. Our program traces each adjudication back to an individual prescription number and dispensing date. No extrapolation of claims is made with our program; each claim is individually examined for compliance.  The review will involve your pharmacy processor's:

  • Contractual arrangements / rate guarantees

  • Historical utilization

  • Trend profile

  • Financial and savings data

  • Benefit plan design

  • Clinical and cost containment programs

  • Implementation processes

Actionable Information

Our pharamcy consulting staff has many years experience managing and controlling rising pharmacy costs.  Our staff will review your pharamcy benefit programs to ensure that the plan meets your organization's requirements.  Actionable information is our core deliverable - information that can help you recover overpayments, negotiate favorable plan terms, and foster a benefits environment that delivers the highest quality care while managing costs.
We bring to bear on your challenges years of experience working with many of the nation's leading insurance companies, Third Party Administrators (TPAs), pharmacy benefit managers, and employer groups. This experience is passed on to our clients to facilitate decision-making and address complex issues.
If you're looking for a high quality consulting product that delivers excellent value and highly personal service, turn to the Seneca Consulting Group.