Segal Company

Claim Audits and Implementation Reviews

Since 1973, Segal has conducted scores of retrospective on-site claims reviews of public sector health plans administered internally or by third-party administrators.

Our consultants have extensive background in claims processing and operational reviews. 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.


Segal will work with you to determine what your greatest challenges are. We can target our reviews to the areas that make an impact on the bottom line or that best support your plan's overall goals.


We tailor each audit project to the plan's specific concerns and objectives. We offer an array of services and tools 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
  • Analysis of Claims Data to determine utilization trends and comparisons
  • Claims System Logic Testing of system capabilities, examiner edits and automated benefit calculations
  • Duplicate Claims Analysis to electronically identify potential overpayments that may have bypassed system edits
  • Electronic Eligibility Review to compare multiple data sets and identify discrepancies that impact claims processing and/or suggest administrative deficiencies
  • Implementation Audits before and after a change in vendors or plan design are critical for early detection of potential system errors.
    • Post-Implementation Assessments of plan setup, adjudication procedures and automated system capabilities before going into production
    • Pre-Implementation Review to assess established procedures and system capabilities of a new administrator or examine a major benefit revision
  • Performance Validation to ensure correct operation of claims-adjudication procedures
  • Periodic Claims Reviews to meet fiduciary responsibilities, validate plan costs, enforce or implement performance guarantees, address benefit concerns and increase participant satisfaction
    • Stratified Samples offer overall confidence in the processing accuracy for all claims
    • Targeted Samples validate areas of concern or claims identified through electronic queries
  • Specific Stop-Loss Coverage Analysis to confirm appropriate procedures are in place for prompt filing and accurate reimbursement

Claims Process