FOCUSED SAMPLE CLAIM AUDITS

A Focused Sample Claim Audit is intended to identify overpaid claims and recover overpaid monies for the plan sponsor. We conduct some Focused Sample Claim Audits on a contingency fee; others involve a base fee. It depends on the size of your plan, the plan administrator you use, the provider networks you utilize, etc.

Two-thirds of all medical claims dollars are spent on claims with paid amounts of $1,000 or more, so that is where these audits are focused - on large dollar claims that have the most financial impact to you. Each audit covers a 12 to 18 month timeframe. We select audit claims based on criteria we have developed over the years of claims most likely to be overpaid. The number of claims audited depends on the size of your plan, but most ASO and TPA firms limit such audits to about 250 claims.

Each claims selected for audit is reviewed for the following key issues:

• Was the patient eligible for coverage on the date of service?
• Was there any other third party liability involved in the claim? (i.e. Worker's Comp, an auto carrier, etc.)
• Was there over coverage that should have been primary?
• Does the plan cover the services provided?
• Were any coverage limitations exceeded?
• Did the employer receive all applicable provider network discounts?
• Was the claim paid only one time?

Each year, we recover millions of dollars for plan sponsors. The average overpayment we find on an individual claim is $2,500. However, each year we find many claims overpaid by $25,000; $50,000; or $100,000. In one audit, we found one claim that was overpaid by $480,000!

Go to EXAMPLES OF AUDIT RESULTS for an overview of the types of payment errors we find in these audits.