Statistically valid Sample audit

The large sample audit provides statistical relevance to the entire claims population and is often used to establish, or enforce, performance guarantees. This audit also allows for comparison to administrator and industry standards. A large claim sample is randomly selected and stratified by paid amount to conduct the performance audit. Typically, medical audits are conducted onsite at the administrator and pharmacy audits are "desk" audits conducted in our office.


Issue identification audit

The small sample audit provides a snapshot of plan performance but results may not be indicative of the entire claim population. A small claim sample is randomly selected for this performance audit. Comparisons to administrator and industry standards are informational.

Pre/Post Implementation Audit

Allows for review of how claims will be administered before actual claims are paid. An extremely cost effective way to measure plan performance and identify savings before incorrect payments are made. Usually conducted prior to (or shortly after) implementation of a new plan with an administrator, or after significant plan design changes. When changing to a new administrator this audit is popular with employers because the administrator will often fund the audit.

Targeted sample audit

Performed in conjunction with either the large or small random sample audit, the targeted sample allows claims to be selected based upon specific criteria. Although target criteria are determined through discussion with our client, typical criteria include high-dollar paid claims, complex claims, coordination of benefit with primary coverage claims (other group insurance and/or Medicare) case managed claims, reinsurance claims, or other claim types determined based upon employee feedback.


Operational Assessment

A senior member of our audit team conducts interviews with key vendor personnel to determine vendor compliance with internal and industry policies and procedures. This is a review of the administrator from a functional/organizational perspective to ensure that proper controls are in place for plan administration.

Electronic Claim Audit

100% of all claims for a specified time period are reviewed through the use of database queries and auditor review to determine possible overpayments in the areas of:

  • Eligibility
  • Duplicate Payments
  • Plan provisions/exclusions
  • Coordination of benefits
  • Clinical logic
See also:

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