Q. Why should you conduct a claims audit?
A. It’s your company’s money that is being used to pay the claims. You have a right to know that your money is being handled properly. And, as a self-insured plan sponsor, you have a fiduciary obligation to see that claims are being paid properly and that claims costs are kept as low as possible.

Q. How many claims are overpaid?
A. On average, about 5% of all claims we audit are overpaid.

Q. Should you do a claims audit or a procedural audit?
A. It depends on your objectives for the audit. Both types of audits can be productive tools, but they serve different purposes. Tell us what you want to accomplish and what your concerns are, and we can design an audit program specifically for you.

Q. Will your TPA firm cooperate with an audit?
A. Almost all TPA firms are used to audits and have departments set up to handle what they call “external audits.” Your TPA or ASO contract should address your rights to audit, how audits are to be done, audit fees, etc.

Q. How often should you conduct different types of audits?
A. It really depends on the size of your plan. Most of our clients conduct claims audits annually, a procedural audit every few years, and a pharmacy audit every few years. Eligibility audits are relatively new and should be conducted every three or four years, dependent on plan size.

Q. How much of your time does the audit take?
A. Claims audits, procedural audits, and pharmacy audits take very little of the Employer’s time. Eligibility audits do take some interface between ourselves and your representative to the audit, but the potential return is worth the investment.

Q. Who are some of our clients?
A. MedReview audits for some of America’s largest and most respected self-insured employers. Our clients come from all industries. Even some of America’s largest healthcare companies self-insure their group health plans and use MedReview audit services. We will be happy to provide specific references upon request.