(520) 529-2010 shicinc@aol.com

Medical Claims Audit Programs

Medical Claims Audit Programs

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