Why perform a health claims audit?

  • The process of paying claims is complicated and the best claims administrators make mistakes.
  • Ensure proper spending of healthcare dollars and confidence in approving wire transfer payments to the claims administrator.
  • Identify and recover lost healthcare dollars.
  • Health plan fund account operates as an “open checkbook” process to the claims administrator and should be reconciled with the same emphasis as the company’s operating bank account.
  • A self-funded plan sponsor has fiduciary responsibility to protect the health fund for its members.
  • An important tool for identifying all types of errors that may continue into the future without intervention.
  • When changes are made to the health benefits plan document, an audit should be performed to validate the changes are consistently loaded into the claims administrator’s system. This prevents conflicts in language interpretations.

Which audit will benefit your Health Plan? 

  • Stratified Random Sample Audit

Will provide objective results of the claims payment accuracy of the claims administrator. It identifies both overpaid and underpaid claims and is based upon stratification of all claim types and dollar amounts. The Administrative Services Agreement most often allows this type of audit in addition to a small sample of focused claims in areas of high dollar cases. 

  • Focused Sample Audit

A focused audit can be requested by the employer group for specific areas of paid health claims. Some of those areas are but not limited to high dollar claims, excessive lengths of stay, surgeries, out of state provider claims, cases involving potential litigation, network discounts, duplicate payments, ineligible participants, coordination of benefits and stop-loss member claims. The Administrative Service Agreement may restrict this type of audit but should be discussed with the claims administrator to request an amendment in order to request the audit that will benefit your company. The focused sample audit will result in the highest number of overpayments. 

  • Electronic Claims Audit

An electronic claims audit will review all claims in the audit scope. HCCI creates programs and queries to review and analyze 100% of the electronic claims file submitted by the claims administrator. Areas reviewed but not limited in the electronic edits are duplicate payments, plan exclusions, provider payment analysis, rejection codes, subrogation, non-par provider rates, member eligibility/status, and application of benefits. An electronic claims audit can be performed from the audit company’s location,
however, it is completed by an onsite validation to review the results with the claims administrator.