Claims Audit Services for Employers

A comprehensive retrospective and prospective review of all claims and financial data provided or obtainable by your insurer or plan administrator utilizing audit methodology unique to our organization.  The results of the audit will allow premium billing reductions and / or claims payment credits or cash returns which will enable you to better afford your medical programs in future years.  The audit will include the current renewal year and up to five (5) previous renewal / settlement years. Our fees are based strictly on a contingency arrangement and are payable by you only if you realize billing reductions, credits and/or cash returns from the insurer and / or medical plan administrator.

Physician Compliance Audits

On a Prospective and yearly basis, select for review and audit a predetermined sampling (individual patient cases), based on the physician practice, for which third party payor payments have been made and match them against patient medical records to ensure the Physician has complied with the regulations and procedures as they relate to the third party payors operational methodology. Provide to the Client a report which indicates their performance and potential for overpayments by the third party payor, which will include recommendations to avoid criticism or cash call-backs by a third party payor.

If our services are in response to a third party payor audit, we will review and re-audit all samplings which a third party payor has selected for specific periods on individual patient cases whereby the third party payor is disputing payments previously made to the Client. Provide to the third party payor documentation, reports, other data, additional findings which effectively mitigate the Client’s alleged liability. Negotiate with the third party payor on behalf of the Client and ensure that the Client has received the best financial arrangement possible with the third party payor.

Claims Audit Services for Brokers

Claims auditing can provide three key benefits for insurance brokers, Time Savings, Client Satisfaction, & Dollar Savings.