Our health claims audits involve a thorough review and examination of healthcare-related claims, carried out by insurance companies or third-party organizations. The purpose is to ensure the accuracy, validity, and compliance of claims made by healthcare providers and patients. We assess medical records, billing documents, eligibility and other relevant information to confirm that services were provided as claimed, and that the claims follow the guidelines established by the Plan. This helps prevent fraud, waste, and abuse in the Plans, and ensures that payments are accurate and appropriate.
Eligibility audits can be performed in conjunction with a health claims audit or independently.
Since our health claims audits are customizable based on the needs of your Plan, the audit process begins with defining the scope, objectives, and parameters of the audit. The audit team gathers information about the Plan, claims submission processes, and relevant regulations.
We obtain databases from the different service providers processing health, dental, vision and prescriptions claims. Eligibility databases are also obtained if they are part of the audit. Customized tests are performed and a sample is selected. This sample may include a variety of claims types, such as medical treatments, procedures, prescriptions, and diagnostic tests.
We meticulously examine the supporting documentation for each claim. This includes medical records, invoices, bills, and other relevant documents. The claims are assessed against the established Plan rules. This includes coverage limits, exclusions, pre-authorization requirements, and other policy provisions.
Once the audit is complete, we prepare a comprehensive report detailing our findings, including any instances of non-compliance, errors, or discrepancies. We will work with the other plan professionals in order to rectify any identified issues.
1. Preventing Fraud and Abuse: Audits may help identify fraudulent or exaggerated claims, preventing dishonest individuals or providers from taking advantage of the system.
2. Ensuring Accuracy: Mistakes can occur during the claims submission and processing process. Audits help identify errors in coding, billing, and documentation, ensuring that claims are accurately represented and reimbursed.
3. Promoting Transparency: Audits provide transparency in the healthcare system by ensuring that claims are processed and paid in accordance with established Plan rules. This transparency builds trust among members, providers, and administrators.
4. Managing Costs: Incorrectly processed claims can result in overpayments. By identifying and rectifying these errors, audits help Plans manage costs and allocate resources more efficiently.
5. Preventing Overutilization: Audits can detect patterns of overutilization of healthcare services, which can strain the Plan's resources. By identifying and addressing such patterns, audits help control healthcare costs.
6. Data-Driven Insights: Our audits involve data analysis, which can provide valuable insights into the healthcare utilization patterns of members. This information can be used to develop more effective coverage options and wellness programs.
7. Deterrence: The knowledge that claims are subject to audits can discourage fraudulent activities and encourage providers to adhere to proper coding and billing practices.
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