Claim Audit

The U.S. private-sector health insurance industry spends $30 Billion each year administering claims. Processing claims is complex. Does your organization have the appropriate measures in place to validate proper claims payments? With health care costs continuing to rise and corporate liability increasing, can your organization afford not to audit?

Why should my organization perform a claim audit?

Control Wasteful Spending

One of the largest studies of third party claim payment accuracy found the error rate to be over 10 percent.2


Comply with the Law

A claim audit provides valuable feedback and proof that your organization is maintaining its fiduciary obligation under ERISA.


Reduce Future Costs

Regular audits send a clear signal to your organization’s benefit administrator that you are taking an active role in ensuring that they are minimizing costs. This will help your organization’s plan operate more efficiently.

How does the Chapman Kelly Claim Audit process work?

  1. Gathering Information – You supply us with your plan documents, enrollment data, and a short questionnaire that we will use during the course of the audit. Your administrator will supply us with the claims information.
  2. Data Interpretation and Auditing– Chapman Kelly uses its well-versed audit staff and cutting-edge technology to interpret your data. Our internally developed MAX™ software platform has analyzed over $10 billion in claims data from every national carrier.
  3. Sample Selection – Chapman Kelly will select a sample that fitsyour organization’s objectives. The matrix below will give you a high-level overview of our three sample selection methods.

      AUDIT TYPE
      Comprehensive Hybrid Random
    Primary Objective Met Identification and Recovery of a Significant Number of Overpayments Compliance Compliance
    Secondary Objective Met Compliance Identification and Recovery of a Smaller Number of Overpayments A Statistically Valid Measurement of Your Administrator's Performance
    Number of Employees in Plan

  4. Onsite Visit – Our experienced auditors go to your administrator’s office in order to examine the sample claims in their systems.
  5. Reporting and Recovery – Your organization will receive a detailed report of the audit results. Chapman Kelly will walk your organization through the results and discuss recommendations on improving the plan’s compliance and performance.

Why Choose Chapman Kelly?

Knowledge

  • We’ve helped hundreds of companies maximize value and minimize loss associated with health insurance and count over 35 Fortune 500 companies among our clients.
  • Our staff has extensive experience identifying the most complex situations that cause payment errors.

Technology

  • We utilize proprietary technology that we tailor to meet your technical environment, standard operating procedures and plan provisions.
  • Our internally developed MAX™ software platform is continually improved upon by leveraging the expertise of our audit professionals and the technical talent of our software engineers.

Results

“Chapman Kelly was very timely in their delivery and very much ‘on their game’ and did exactly what they said they would. I would definitely use Chapman Kelly again and recommend them to any large business.”

-Bryan Cross , U.S. Sugar

1. The Wall Street Journal (New York, NY: Dec 2007)

2. Centers for Medicare and Medicaid Services, Improper Medicare Fee-For-Service Payments Report, (Baltimore, MD:November 2005)