Medical Claims Audits

Every self-funded medical plan should invest in a comprehensive Medical Claims Audit to evaluate the accuracy of claims processing and identify areas where corrective action is necessary. Error rates in healthcare range from 1% to 3%, not including fraud, and the goal with every audit is to identify claim payment errors and recover some of these expenses. Our team will identify overcharges, missed coordination-of-benefit opportunities and deviations from plan specifications.

Customized Audit Strategy

There are many different approaches to auditing medical claims including random sample, targeted, and recovery-focused projects. We begin every project by listening to the objectives of the organization, and discussing the audit rights language in the administrative services agreement with the claims payer. After gathering the necessary background information, we are then able to customize the project scope to fit the Clients’ needs, and budget. All of our Medical Claims Audits entail very little Client involvement and are as unobtrusive as possible for both the Client and Claims Payer(s).

The targeted and recovery-focused audits include data mining of all paid claims for the plan covering a wide variety of potential errors. The sample for the claims audit is selected from the results of this data mining process, so claims are reviewed based on their potential as errors. This detailed focus on exceptions and errors allows for identification of plan improvement opportunities, clarification on plan interpretation, and root causes that can be corrected for future cost savings.

Overpayment Recovery Tracking

At the end of the project, we will assist with tracking the recovery of overpayments and provide recommendations for process improvements that can reduce future expenses. Medical Claims Audits produce a tremendous return-on-investment. The recovery of overpayments typically pays for most, or all, of the project costs and the root-cause corrections generate future cost savings.

We are so confident in the success of our combined Claims Audit and Dependent Eligibility Verification projects that we provide a positive return-on-investment guarantee.

Dependent Eligibility Verification

Learn more about this critical component of managing compliance and controlling costs for all of your health plans.