Home     Services     Profile     Contact     Affiliates

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.

top