Audit Basics
Both fully insured and self-funded health plans benefit from periodic claims audits. An audit provides a seminary effect, putting the administrator on notice that the quality of their services will be monitored. Typical claim categories included are: accuracy of benefits paid relative to plan design, eligibility, evaluation of proper coding, promptness of claims payments, application of network discounts, and application of subrogation and/or coordination of benefits. Eligibility audits are also available upon request.
At the conclusion of the audit, a detailed written report is produced, outlining the audit findings, including recommendations to cure any discrepancies and an assessment of any financial penalties applicable, consistent with any contracts or agreements in place.
Audit Elements
- Overall Accuracy – The percentage of claims processed correctly in every aspect, including; coding, payment to the correct party, financial accuracy, and turnaround time.
- Financial Accuracy – The total sum of absolute dollars of all underpayments and all over-payments divided by the total dollars of claims paid.
- Turnaround Time – Number of working days elapsed between the date the claim is received by the claims paying vendor and the date the claim is either processed for payment, processed for denial, or pended for further information and/or documentation.
- Eligibility – Verification of coverage at the point of service.
Auditor Experience
Brenda Sadler, Crowne’s primary auditor, has over 20 years of auditing experience, having conducted audits of numerous third party administrators and insurance carriers. A more detailed profile of Ms. Sadler’s auditing experience is available by written request.