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.