Health & Welfare Consulting

Medical Claims Audits

We thoroughly audit medical claims to help ensure that they are paid accurately and according to your plan design, with copayments and coinsurance applied correctly. Our audits include an analysis of any potential claims subrogation opportunities that may result from overpayment of claims that were eligible for coordination of benefits (COB), Workers' Compensation, auto insurance, or other types of liability insurance outside your plan.

Our medical claims audits:

Review your agreement with the carrier regarding healthcare benefit administration and financial settlements.
Review the carrier's healthcare benefit plan summaries and benefit descriptions, with particular attention to areas that are subject to the agreed terms of the arrangement between you and the carrier.
Discover any potential claims subrogation opportunities resulting from overpayment of claims
Stratify the claims extract file into less than and greater than $50,000 claims, with further stratification into predetermined categories (such as outpatient, outpatient and physician), to establish a proportionate stratified random sample.
The sampling objective is to achieve a 95% confidence level and +/-3% confidence interval.
The auditor anticipates examining a proportionate stratified random sample of approximately 150 to 200 claims.
Actual review may encompass additional claims, as much as 50% of the sample size, in order to determine proper and accurate application of the out-of-pocket maximums.
Draw a proportionate stratified random sample to reflect populations in accordance with the above.
Determine and segregate claim adjudication errors that are systemic versus ad-hoc/non-systemic.
Calculate the impact of errors and various statistics on sample findings.
Submit our draft report of audit findings to you and the carrier.
Independently evaluate the quality and accuracy of overall claims administration, including establishment and comparison of an error rate to industry norms.
Assess the timeliness of claim payments and its effect on accuracy.
Assess the carrier's quality control and audit program, including in-house training programs, frequency of audits, and types of audits performed.

Audit sample claims to meet the following objectives:
Carrier payments for claims charged to you that were made on behalf of your covered members
Payments to providers made consistent with the underlying contracts
Determination of appropriate liable parties, based upon the client subscriber agreement (i.e., covered services, deductibles and coinsurance amounts properly determined and billed), site of occurrence, or nature of the claim (subrogation, Workers' Compensation, COB, auto, etc.)