Due to the high costs associated with providing comprehensive medical coverage, these types of claims audits are most popular with self-insured organizations. Lasting anywhere from 4-6 months dependent on a variety of circumstances, these audits usually begin with a thorough review of benefit plan design. Most audit firms receive data from the employer’s third-party administrator and then samples are selected for closer examination. Depending on the audit approach, some firms may employ technology to aid in sample selection. These samples should be examined further onsite at the third-party administrator’s claim payment facility where more pertinent claims processing information is made available.

Depending on the audit firm, audit approach, and technology used, medical claims audits can uncover a wide variety of claims adjudication issues and/or weaknesses such as system limitations, plan-build inaccuracies, overuse of processor overrides, and provider billing errors.

You can read more about our Medical Claims Audit on our blog.