Electronic Claim Audits are specifically designed to verify whether or not your plan is being administered as it is designed. We examine each and every claim paid during a specified time period. Instead of relying on an audit sample, we load an entire claims file into our software and review each and every claim for payment accuracy. Any claim paid or processed in a manner contrary to your plan specifications is identified.

Each audit is customized to address each plan sponsor's specific concerns. However, some of the issues we can address are as follows:

• Was the patient eligible for plan coverage on the date of service?
• Were any services provided that are not covered by the plan?
• Were any coverage limitations exceeded?
• Should another carrier have been the primary coverage? If so, were the plan's COB provisions correctly applied?
• Were plan co-pays and co-insurance amounts correctly calculated?
• After all adjustments, was each claim paid only one time?

Electronic Claim Audits are conducted on a fixed fee basis, which varies with plan size. In addition, an Electronic Claim Audit can easily be combined with an Operational Review or with a Claim Re-Pricing Review for an additional fee.

If you don't want to rely on just a sampling of claims and if you want to verify any and all discrepancies in the benefits administration of your plan, an Electronic Claim Audit may be your answer.

Go to EXAMPLES OF AUDIT RESULTS for an overview of the types of claims payment errors we discover in our claims audits.