Self-funded health and welfare plans should have an outside auditor test claims annually (best practice), but absolutely no less often than once every three years. Under the self-funded arrangement, plan sponsors, not insurers, assume the risk. An ongoing claim audit program enables plan sponsors to satisfy their fiduciary obligations, monitor costs and potentially identify areas for savings. Additionally, certain organizations may be required by an outside body to have claims audits (e.g., under Washington Administrative Code 200-110-120, self-funded public entities in the state of Washington that sponsor health plans are required to conduct claims audits once every three years.)
Contact Lindquist's Claims Audit Senior Manager Jody Reimler at 925-277-9100 to learn how we can help you.