The ability to understand and identify risks within your organization’s health plan, as well as the likelihood and overall impact, enables our people to customize an engagement that integrates with your risk management process and risk appetite.
The goal of these engagements is to work in conjunction with your risk management process, instead of as a stand-alone engagement, to eliminate unacceptable risks; reduce unacceptable risks to an “acceptable” level if the risks cannot be eliminated; or transfer unacceptable risks.
Healthcare Claims Audit
Read our article, How to Plan and Design a Thorough Health Care Claims Audit.
Even the industry’s best claim administrators are estimated to have claim payment error rates that range from 2% to 5% of overall medical claims costs each year. Can you continue to afford to ignore this risk?
A healthcare claims audit is defined as an independent and objective examination and analysis of (a portion or the entirety of) a third party administrator’s claims adjudication process, pursuant to plan guidelines and generally accepted industry standards. This evaluation may take place prior to the implementation of plan benefits (i.e., a pre-implementation audit) or after plan benefit adjudication has begun (i.e., post-implementation or retrospective audit).
Clients routinely engage us to evaluate the administration of:
- Medical Benefits
- Mental Health and Substance Abuse Benefits
- Dental Benefits
- Vision Benefits
- Supplemental Sickness/Disability Benefits
- Flexible Spending Account
Going well beyond the traditional healthcare claims audit, our multidisciplinary auditors utilize a risk-based engagement approach to identify, target, assess and mitigate key risks within the claim cycle for the purpose of safeguarding assets. Our auditors work collaboratively with third party administrator’s to maximize engagement results and recovery opportunities. Engagements may incorporate one or more of the following service offerings: