The first portion of the audit involves an on-site interview to ascertain the number and credentials of personnel involved in processing the claims.  An overall claims procedure (from the time the claim is received until the final payment is released) is diagrammed and appraised.

A selected random sample of claims from a specific period is totally re-adjudicated by our auditors.  This portion of the audit appraises payment and claims system.

An exit meeting is held with the claims director to clarify our findings and insure the accuracy of our results.  The final report is formulated and forwarded to the client.

A description and appraisal of on-site review and general narrative.

Itemization of erroneous claims with detailed explanation.

A complete statistical summary.

Evaluate the effectiveness of the administrative process.

Assess, based on a limited number of claims, the accuracy and consistency of claims processing.

Document control or processing errors noted during the course of performing the aforementioned procedures.

Measure turnaround time.

Assess claim processor compliance with cost containment program requirements.

Perform a general operational review to identify area of administrative efficiency that the TPA may wish to implement.

Identify areas for potential improvement.

Obtain and read a summary of the provision of the Plan.

Meet with the TPA claims administration and discuss the claims administration operations.

Select a random sample of 450 claims per audit paid processed during the selected period to determine adherence to the plan's provisions.  The sample is selected by a formulated listing provided to us by the TPA.  The number of sample claims selected is based on a confidence level of 95% and a precision limit of 5%.

Discuss the computerized claims system and observe a demonstration of the system.

Discuss the claims adjudication capabilities of the system with the claims personnel and document its functions and processes.

Discuss and observe the system's security features through discussion with and observation of claims personnel.

Comment on the security system based upon our observations in the claims administration industry.

Through discussions with claims administration personnel and through observation of claim office workflow and operation obtain and document an understanding of claim office procedures.

Discuss with claims personnel the procedures in place to ensure quality control of claims processing and payment.

Discuss with claims personnel the manual and computerized claims adjudication processes.

Define a claim sample item as an EOB.

Compare the documentation for the sample of claims selected for accuracy and adherence to the provisions of the plan.

Read documentation associated with each claim.

Compare claim documentation with claim payment produced by the system, according to plan benefits provisions.

Complete a claim review worksheet for each claim sample.


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Mullally Insurance Services Inc.  ◊  2665 N. Atlantic Ave, Suite 325  ◊  Daytona Beach, FL  32118
Phone: (813) 973-8700