Most claims never get checked. That is where the waste hides.
Medical and pharmacy claims are paid on trust far more often than employers realize. On a fully insured plan that is the carrier’s problem. On a level-funded or self-funded plan it is yours, and nobody sends you a notice when a claim is paid twice, priced outside the contract, or billed for a service the plan excludes.
The same three patterns, at almost every group.
Payment integrity work is unglamorous and specific. It looks at individual claims rather than at the loss ratio, which is why it finds things a renewal analysis never will.
Duplicates and Rebills
The same service paid twice under slightly different codes or dates, or a corrected claim paid alongside the original. Routine, recoverable, and invisible in aggregate reporting.
Contract-Rate Mismatches
A claim paid at a rate the network contract does not support. Finding these requires comparing the payment against the contract, which is exactly the comparison nobody performs by default.
Eligibility and Coordination Errors
Claims paid for people who were not covered on the date of service, or paid as primary when another plan should have paid first. The same upstream eligibility problem that causes wrongful denials also causes wrongful payments.
Finding the error is the easy half. Getting the money back has a clock on it.
Every plan document and network agreement limits how far back a payment can be revisited, and the clock runs from the payment date, not from the day you noticed. An audit that lands after that window closes produces a report, not a refund.
What Is Actually Recoverable
A duplicate payment and a contract-rate error are recoverable as a matter of contract. A medical-necessity judgment usually is not. Sorting findings into those two piles before anyone writes a letter is what keeps the exercise from becoming a standoff with your own carrier.
Who Pursues It
On a self-funded plan the money is yours, and the claim goes back through the administrator under your plan document. On a fully insured plan the carrier keeps it, and what the error buys you is leverage at renewal. Those are two different arguments, and using the wrong one wastes the finding.
The Window
Corrections have to be raised inside the plan’s own billing-adjustment window, which is why this runs on a cadence instead of as a year-end project.
What Comes Back
We do not publish a recovery percentage, because it depends entirely on what the audit finds and how old it is. What you get before we start is which findings are inside the window and which are not.
Stop-Loss Reimbursement
On a self-funded plan the largest single recovery is often not an audit finding at all — it is a claim that breached the specific deductible and was never filed the way the contract required. We run that filing against the contract’s own notice and proof-of-loss deadlines.
Medical claims are the biggest line, not the only one.
The same discipline applies anywhere a third party pays money on your behalf, against rules somebody else wrote.
Dependent Eligibility Verification
An ex-spouse who was never removed and an adult child past the age limit stay covered until somebody checks. On a self-funded plan you pay those claims in full, and the correction is permanent rather than a one-time refund, which is what makes this the highest-return review on the list. It also runs as a standing check rather than a one-time sweep, because eligibility goes wrong again the moment a life event is not reported.
Pharmacy Claims, Discounts and Rebates
A pharmacy audit tests something a medical audit cannot: whether the discounts, dispensing fees and rebate guarantees written into your contract are the ones actually applied. A guarantee nobody measures against is a sentence, not a term.
Dental, Vision and the Account Balances
The smaller lines get less scrutiny for exactly the reason they deserve some. Dental and vision claims, COBRA premium accounting, and HSA, HRA and FSA balances all reconcile the same way, against eligibility and against the plan rules.
Medicare Part D and Retiree Coverage
Retiree drug coverage carries its own subsidy and disclosure rules, so an error there costs you twice: once in claims and once in a compliance position you would rather not have to defend. A subsidy determination can be reopened at the sponsor’s request, within a year for any reason and up to four years where there is new evidence or a computation error, so a year that came up short is worth revisiting while it still can be.
Hospital prices vary more than quality does.
Published research on hospital pricing gives employers something they never had: an external reference point. Analysis of commercial claims has found private plans paying hospitals in the region of two and a half times what Medicare pays for the same services, with wide variation between facilities in the same market.
Network Cost and Quality Data
We push carriers and vendors for real cost and quality data by provider rather than accepting a network’s reputation as the whole story. Transparency requirements have made more of this available than most employers use.
Where the Steering Is Worth It
When a facility in the same network costs several times another for the same procedure, plan design and employee guidance can move volume without restricting anyone’s care.
Reference-Based Pricing, Honestly
A reference-based approach can change the arithmetic considerably. It also changes the employee experience, and both belong in the decision. We advise on it case by case rather than placing a program.
A finding is worthless until somebody acts on it.
Holding the Vendor to It
A correction that is agreed and then not made is not a correction, so the same claims get pulled again the following month to confirm the money actually moved.
Billing Reconciliation Every Month
The carrier invoice checked against enrollment so the error is caught in the month it happens, when it is still a correction rather than a negotiation.
Reporting You Can Act On
Claims, pharmacy and stop-loss data in one view with outliers flagged, so the audit question is asked during the year rather than after it.
What employers ask about claims auditing.
Do claims really get paid incorrectly?
Often enough to be worth checking. Duplicates, rebills and contract-rate mismatches are ordinary, and on a self-funded plan every one of them is your money rather than the carrier’s.
Is reference-based pricing a good idea?
It can lower cost, and it moves risk onto employees when a provider balance-bills. It works where it is paired with real member support; it fails where it is sold as a pricing mechanism on its own.
What do we do with the findings?
Recover them. An audit producing a report and no recovery has cost you the audit fee, so the engagement should be judged on what came back rather than on what was found.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Bloomfield Hills, MI 48304
248.370.8853
Colorado Springs, CO 80921
719.425.2649
Houston, TX 77084
281.404.5670