Segal Company

Claim and Eligibility Audits

Since 1973, Segal has conducted scores of retrospective on-site claims audits of public sector health plans.

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 plan'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
  • Duplicate Claims Analysis to electronically identify potential overpayments that may have bypassed system edits
  • Electronic Eligibility Review comparing multiple data sets
  • Performance Validation to ensure correct operation of claims-adjudication procedures
  • 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 Audits 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

You should 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 employees and dependents.