Claim and Eligibility Audits

Since 1973, The Segal Company has conducted scores of retrospective on-site claims audits of multi-employer health funds.

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 fund'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
Performance Validation to ensure correct operation of claims-adjudication procedures

Eligibility Audits

Estimates suggest that eligibility errors are prevalent in health plans. In fact, eligibility audits are reported to produce 10 - 15% reductions in the number of eligible dependents. To protect against financial losses, it is imperative for group health plans to use eligibility safeguards and perform audits.

Segal can conduct eligibility audits to identify:

Overage children and ex-spouses who no longer meet dependent definitions
Administrative procedures that fail to recognize and determine full-time student status and/or coordination of benefits
Late termination notices to claims staff and the lack of procedures for reviewing ineligible claim payments

You should consider an audit if your plan:

Does not require positive enrollment
Recently changed administrative service providers
Does not receive and validate monthly adds/deletions from its administrator

Strategies and recommendations for eligibility audits vary based on group size and benefit philosophy. Segal can help plan sponsors establish appropriate controls to ensure that benefits are only paid for eligible participants and dependents.