Pre-implementation audits are becoming more popular with organizations who may be changing third-party administrators, making significant changes to benefit plan design or moving to self-insured plans for the 1st time. Though third-party administrators do their own plan testing before implementation, information being programmed may not be consistent with plan language or intent. Many organizations believe it is critical to find and correct discrepancies before actual claims are paid. It is also not uncommon for an organization to conduct a complete claims audit post-implementation for additional assurance.

Typically these audits are performed on a live-remote basis allowing the audit firm to review plan documentation against the system setup. Dependent on the audit firm, audit approach, and technology used, the auditor may use existing and/or customized claim testing scenarios. Areas of testing may include deductibles, copay levels and application, out-of-pocket rules, exclusions or limitations.

You can read more about our Pre-Implementation Claims Audit on our blog.