Auditing Your Benefit Payments | Claims Audit Objectives | After the Claims Audit Fieldwork

Auditing Your Benefit Payments

Whether your health plan is self-insured, experience-rated or fully insured, claims auditing is something that needs to be done routinely. In order to ensure that your claims payor has adequate controls in place to effectively administer your plan and pay claims in a timely and accurate manner, it is critical that you implement an ongoing claims audit program.

At Lindquist LLP, we determine our claims audit procedures and processes only after gaining a thorough understanding of your plan and how it operates. Our knowledge of your industry allows us to work with you to concentrate our efforts on significant accounts and potential high-risk areas.

Unique Claims Audit Expertise

Lindquist LLP has professional staff members who work exclusively in claims auditing and related areas involving the improvement of efficiency and control of claims processing. All personnel within this department have more than 20 years of experience performing and supervising audits of benefit claims. Our staff is knowledgeable in auditing claims and reviewing claims systems as well as analyzing internal controls.

^ top

Claims Audit Objectives

The basic objective of a claims audit is to determine that payments were made for eligible participants, for covered benefits and for the correct amount. Claims audits should include:

• Review of the benefit calculations against any scheduled benefits or usual, customary and reasonable allowances, proper deductible and/or coinsurance application, as well as other plan limitations.
• Review of the claims history for any possible duplicate payments.
• Identification of possible fraudulent activity, such as provider abuse, altered bills, or large dollar benefit payments issued to an employee.
• Focus on specific issues such as coordination of benefits, subrogation or effectiveness of utilization review.

Claims audits should also include an analysis of internal controls, during which the auditor documents his or her understanding of the claim payor’s internal claims processing control structure. The auditor can then assess whether the systems are properly designed to pay claims in accordance with plan provisions and industry standards.

^ top

During fieldwork, any possible discrepancies noted are documented and discussed with the claims administrator. The claims administrator is given time to review our findings and respond accordingly. After receipt of the response, we remove or amend any discrepancies, if necessary, where the claims administrator provides additional information affecting our findings. We analyze the results and conclude the claims audit. A draft report is sent to the claims administrator for review and comment before a final comprehensive report is prepared and presented to the client. The final report presents our findings and the nature and extent of any errors. The report also includes any recommendations for the improvement of claims payment procedures and/or the improvement of any internal control weaknesses that may be noted during our work. If requested, we also present our report.

Copyright 2003-2009 Lindquist LLP