Evaluating Claims Audit Vendors

Shopping for a claims audit is difficult, given the limited exposure to claims audits topics for most employers. Some common issues to pursue in evaluating proposals include:

What is the scope of your auditing process?
Claim audit firms couch their actual scope in lots of verbose language, but the important points you want to know are as follows:

(1) Whether the sample or any portion of it is random. Random sample audits are certainly better than nothing at all, but they are completely different in goals and results than comprehensive audits.

(2) Is the firm in question devoting 50-80% of the sample claims to a random selection? That blended approach is most akin to a random sample with some slightly improved opportunity to find targeted errors. For these types and vendors that propose a completely non-random audit, find out exactly what they are testing across the entire data set with particular focus on how they test benefits.

(3) Specific details on non-random testing – Many firms claim to test everything across the entire data set, but very few firms truly test benefits in detail. Ask for a specific list of queries that will be run for the non-random portion of any claims audit. J. Graham Inc. offers the most thorough audit scope in the market.

Do you offer any guarantee?
Contingency pricing sometimes gets a bad reputation in the claims audit market. TPAs never acknowledge the fact that every one of them uses contingency-based auditors to recover overpayment on their fully insured accounts. Are you using one of the top three or four national insurance carriers as your TPA? They each use several contingency audit firms on a daily basis. Some are even allowing these types of recovery efforts on self-insured accounts and passing on not only a vendor fee, but profitable markups to self-insured employer groups for the effort. J. Graham guarantees results under every audit scope. There is absolutely no risk to work with us, and we have yet to work with a client who did not recover overpayments from an audit.

What is a realistic timeline for our healthcare audit?
Timelines in claims audit proposals are notoriously aggressive. They often reflect unrealistic turnaround times from the TPA that can be deflected from the audit vendor when not met. J. Graham Inc. provides a realistic timeline based on years of experience with every major national carrier in the country. We are happy to talk through the timeline in detail with any potential client to make sure you understand reasonable expectations for the project.

Who will be performing my audit?
Many claims auditors promote technology solutions that parse the data and return a
complicated report that creates more work for the employer to understand. Even worse, some separately price audit remediation so that the employer has to pay extra for follow-up. J. Graham offers true experts in this field, and we follow every audit project through to its conclusion. We take on the burden of looking at the details, producing insights and delivering results. We price our services as a turnkey solution, and we don’t use tricks to make our fees look artificially lower.

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