We offer two types of Medical Claims Audits:
Random audit – A statistically valid sample. 115 claims meets standard requirement, over a period of time, to be considered a “random sampling”. Random audits are best used to identify previously unidentified areas of concern and provide a valid method of evaluating a company.
Focused audit – A focused sample targets specific areas of concerns, such as fraud & abuse, unbundling, large claims, eligibility, subrogation, etc. The number of claims selected is dependent upon your needs.
Our area of expertise is a focused fraud & abuse vulnerability audit and assessment.
Audits can address the following issues:
- Evaluate the client’s plan booklets in terms of consistency, ambiguities, accuracy and intent;
- Assess the accuracy and consistency of claim processing;
- Determine the effectiveness of the administrator in controlling claim costs and protecting against fraud & abuse;
- Identify specific overpayments that may be recovered to the plan;
- Estimate error in paid claims, and sources or trends of errors;
- Assess the effectiveness of customer service;
- Measure time service;
- Evaluate HIPAA compliance;
- Identify areas of potential improvement and provide recommendations to effect better service and reduce costs; and
- Provide the client with a basis of evaluating their client’s performance against standards and guidelines currently used in the industry, if applicable