Claim Processing Audits

Claim Audits provide a detailed overview of a claim payor’s claim handling guidelines and procedures, with a significant focus on the claims department’s systems.

Our auditors evaluate:

      • Efficiency and accuracy of claim payments
      • Built-in security features and edits
      • Reporting capabilities
      • Proper coding of plan benefits and benefit levels
      • Established claim payment authority
      • Separation of functions between claim payment, eligibility entry and provider entry
      • Accuracy of claim benefits relative to the group benefit plan provisions.

Testing of each claim includes:

    • Eligibility verification
    • Coordination of benefits
    • Duplicate payments
    • Benefit limitations and maximums
    • Pre-existing conditions
    • Other party liability

Financial reviews quantify the monetary effects of payment errors on the plan. The minimum acceptable accuracy rates – the difference between the total dollars paid and the total dollars paid incorrectly – is generally 99 percent. The financial review identifies overpayments and the costs associated to the plan, based on a random sampling of all claims.

By performing focused reviews, IR&AS identifies claims with high-risk factors, such as:

        • Medically complex cases
        • High-dollar cases
        • Claims requiring higher level examiner interaction

A procedural review permits the audit team to assess workflow and administrative procedures within the claims department.

The review evaluates:

  • Processes for identifying payments made outside the plan document and excess loss policy
  • The Claims Department’s investigative procedures
  • Verification of claim lag or turnaround time

The procedural review also tracks the number of claims that were handled appropriately, which determines the procedural accuracy rate.