Segal Company

Claim Audits

Sibson Consulting has conducted scores of retrospective on-site claims audits of health plans. As prior claims examiners, our auditors have extensive background in claims processing and auditing. This experience makes them uniquely qualified to evaluate established administrative procedures, suggest areas for improvement and ensure proper controls are in place for efficient plan administration.

Each audit project is tailored to the organization's specific concerns and objectives. We offer a multitude of services relating to claims adjudication of all plan expenses (i.e., medical, dental, disability, vision, life insurance). They include:

  • Administrative Procedures Review of day-to-day operational processes and claim-control measures in place for efficient plan administration
  • Claims System Logic Testing of system capabilities, examiner edits and automated benefit calculations
  • Electronic Eligibility Review comparing multiple data sets
  • Duplicate Claims Analysis to electronically identify potential overpayments that may have bypassed system edits
  • Pre-Implementation Review to assess established procedures and system capabilities of a new administrator or examine a major benefit revision
  • Stratified and/or Targeted Sample Audits to manually review the accuracy of sampled payments to plan provisions and industry best practices
  • Specific Stop-Loss Coverage Analysis to confirm appropriate procedures are in place for prompt filing and accurate reimbursement
  • Performance Validation to ensure correct operation of claims-adjudication procedures

You should consider an audit if your plan:

  • Does not require certified dependent documentation
  • Recently changed administrative service providers
  • Has recently experienced a merger or acquisition
  • Has a high turnover rate or collects enrollment information from multiple departments
  • Does not receive and validate monthly adds/drops from its administrator

Strategies and recommendations for eligibility audits vary based on group size and benefit philosophy.