Segal Company

Claim and Eligibility Audits

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 review. 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
  • Dependent Eligibility Verifications to identify, report and disenroll ineligible dependents from one or more benefit plans
  • Duplicate Claims Analysis to electronically identify potential overpayments that may have bypassed system edits
  • Electronic Eligibility Review to compare multiple data sets
  • 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
  • Post-Implementation Assessments of plan setup, adjudication procedures and automated system capabilities
  • Pre-Implementation Review to assess established procedures and system capabilities of a new administrator or examine a major benefit revision
  • Specific Stop-Loss Coverage Analysis to confirm appropriate procedures are in place for prompt filing and accurate reimbursement
  • Stratified and/or Targeted Sample  selections to manually review the accuracy of sampled payments to plan provisions and industry best practices

Eligibility Audits

Nationwide 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:

  • Social security numbers that are not on plan sponsors' records, resulting in increased administrative fees and potential overpaid claims
  • 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

Should you audit your plan?
Consider an audit if your plan:

  • Does not require certified dependent documentation
  • Recently changed administrative service providers
  • Does not receive and validate monthly adds/drops 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.

Claims Process