Medical, Dental and Pharmacy Auditing

The County of Orange, California, through its County Executive Office - CPO on behalf of Employee Benefits, is soliciting proposals for Medical, Dental and Pharmacy Auditing services. This fully electronic Request for Proposals (RFP) seeks a qualified firm to conduct comprehensive claims, rebates, and operational audits of the County's self-funded health and dental PPO plans. The scope includes auditing five self-insured PPO health plans, one self-insured dental plan, and pharmacy benefit plans, with specific audit periods for medical claims (2025 and 2028), dental claims (2027), and pharmacy claims (2026 and 2029). Respondents must meet minimum qualifications, including at least five years of experience providing auditing services to major public or private organizations and three years of experience auditing health and dental plans comparable to Blue Shield of California and OptumRx. The proposal evaluation will be based on a 1,000-point scoring system, with 600 points for the written proposal, 300 points for presentation/interview, and 100 points for cost proposal. All questions or requests for interpretations must be received by Wednesday, September 24, 2025, before 2:00 pm, with proposals due on October 3, 2025, and an estimated Board of Supervisors approval date of January 13, 2026.

The County has established preference policies for Local Small Businesses (OCLSB) and Disabled Veteran Business Enterprises (DVBE), which can provide additional scoring advantages. The contract is structured for a three-year initial term with one optional two-year renewal, potentially extending to a five-year total engagement. The current medical claims administrator is Blue Shield of California, processing 172,759 medical claims for approximately 5,432 employees and retirees in 2024, with medical expenditures of approximately $58.6 million. The contract will be a firm fixed fee arrangement, with the total contract cost determined by the approved costs proposed by the selected respondent. While specific budget ranges are not explicitly stated, the complexity of auditing multiple health plans for employees and retirees suggests a substantial contract value. The plans to be audited include Sharewell and Wellwise Choice and Retiree Health Plans, covering various employee and retiree populations with different health and prescription drug benefits.