Focused Sample Claim Audits

identify overpaid medical claims

Besides payroll, the biggest expense that a company has is providing healthcare to their employees, yet without conducting an audit of their TPA/Carrier, they have no idea if their claims are being paid correctly or if their benefits have been loaded correctly. The Insurance Companies do not pay nearly as much attention to self-insured clients as they do their fully insured book of business……….it’s not their money.

With our focused audits, we query and test 100% of the paid claims for the audit period to pull a sample of claims that we feel have the potential for financial remedies and are not following the client’s benefit plan. We will select the maximum number of claims allowed by the TPA for the onsite audit. For any error that was validated on the onsite audit, we will test the entire claim file and report on any out of sample errors found and what their financial impact was to the plan.

The focused audit is supported by an Operational Overview of the TPA.

Our final reports include recommendations to plan language to ensure that the plan’s intentions are being adhered to and are not being overridden by the Standard Operating procedures of the Administrator.

MedReview provides post audit support as requested by our client and until our client is satisfied. Categories of error findings typically include:

• Eligibility (claims paid when coverage was not valid)
• Duplicate Payments (all or a portion of a claim was paid more than once)
• Coordination of Benefits (primary payer inconsistency and Medicare COB inaccuracies)
• Subrogation
• Workers Compensation
• Exclusion & Limitations (non-covered services were allowed or Plan limits not applied)
• Medical Coding (all or part of a claim overpaid due to bundling, unbundling or other anomalies)
• Timely Filing (claims were erroneously paid that were received after the claim filing deadline)
• Pricing (claims not priced per the provider contract provisions at key providers or other anomalies)
• Stop Loss Management (specific stop loss claim filing accuracy – if policy information is provided)