How to Plan and Design a Thorough Health Care Claims Audit

A comprehensive health care claims audit protects health plans and participants from mistakes and regulatory violations. This article outlines best practices for planning and conducting an audit.

As health care costs continue to soar, and legislation and compliance grow increasingly complex, more self-insured health plans are conducting comprehensive health care claims audits to safeguard their plans.

What do plan sponsors or trustees need to know about audits to protect plans and plan participants?

It’s essential for self-insured medical plans to hold thorough health care claims audits at regular intervals. Audits protect plans and participants from the mistakes, lapses and regulatory violations that can creep into third-party administrator (TPA) claims processing. An audit may uncover issues that may be occurring without your knowledge, including improper application of co-payments or excluded benefits, payment of benefits in excess of plan limits or for ineligible members, failure to adhere to Affordable Care Act (ACA) regulations regarding essential benefits or patient out-of-pocket maximums, and failure to coordinate with other insurance or Medicare.

Unfortunately, far too many health care claims audits are poorly designed, planned and conducted. The reason? Precious little guidance exists on how to conduct them properly. Plans simply don’t have ready access to established industry best practices and trustworthy guidelines. As a result, audits can leave critical gaps unaddressed and put plans at risk of costly legal actions, damage relationships with participants and tarnish an employment brand.

What are best practices to help design and prepare for a thorough health care claims audit?

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Questions? Contact our Healthcare Assurance and Risk Consulting Team today.

healthcare claims audit article


matt dubnansky cpa

Matthew B. Dubnansky, CPA, CGMA
Partner, Healthcare Assurance and Risk Consulting Team Leader

Matthew has more than 25 years of experience performing assurance and regulatory and risk consulting services for qualified Employee Retirement Income Security Act (ERISA) plans, as well as for their related plan sponsors. He primarily works with complex collectively-bargained union plans, and his clients include some of the firm’s largest Fortune 500 companies.

This article is posted with permission from Benefits Magazine.