Before you commission an audit, three questions decide whether it is worth running.
Claims auditing gets sold as a universal good. It is not. On some plans the data will not support it, on others the recoverable window has already closed, and on a fully insured plan the money that comes back is not yours. Telling you which of those you are in is the first hour of the work, not the pitch.
What decides whether an audit is worth running.
Three things settle it, and none of them is how big the plan is.
Who Holds the Money
On a self-funded or level-funded plan an overpayment is your money and comes back to the plan. On a fully insured plan it is the carrier’s, and the finding converts into renewal leverage instead of a refund. Those are worth different amounts of effort, and it has to be settled before anyone starts counting.
How Old the Payments Are
The correction window runs from the payment date, not from the day the error is found, so the oldest claims in a file are usually the ones nothing can be done about. Knowing where that window closes tells you which part of the file is worth the time.
Whether the Data Exists
An audit needs claim-level detail, not a loss-ratio summary. On a fully insured small group the carrier will not release it, which settles the question before it is asked. On a self-funded plan it sits in the administrator’s system and you are entitled to it.
What we ask for, and what we do with it.
An audit is only as good as the file it runs on, and most of the work is in getting the file right.
The File
Claim-level detail for the period under review, the plan document or certificate, the network terms where you hold them, and the eligibility file as payroll actually keeps it rather than as the carrier believes it to be. The eligibility file gets close attention, because someone on the plan who should not be is an error that repeats every month until it is found.
The Comparison That Finds Errors
Claims against eligibility on the date of service, claims against each other for duplicates and rebills, and paid amounts against the contract terms. Three comparisons, run deliberately, not a fishing expedition through a year of data. Each one produces findings you can act on.
Where It Goes Next
Findings are sorted by whether they are recoverable and whether they are inside the window before anyone is asked to write a letter. An unsorted list of exceptions is how an audit turns into an argument with your own carrier.
What comes back to you, and what it changes.
A Sorted List, Not a Data Dump
Every finding with the amount, the reason it is wrong, and whether it is inside the window. A spreadsheet of flagged claims with no ruling on any of them is work handed back to you. Every line has a ruling.
The Fixes That Stop the Repeat
Most findings trace back to an eligibility file or a billing setup, so the durable value is the correction upstream. Recovering the same error every quarter is not a result. We show where each fix belongs and who has to make it.
A Number You Can Take to Renewal
Payments the plan never owed still sit inside the experience your rates are built on. An error that cannot be recovered can still be argued at renewal, which is where the exercise pays for itself even when no money comes back.
What employers ask before they commission one.
Can you audit a fully insured plan?
Not at claim level, because the carrier owns the experience. What is reviewable is eligibility and premium billing, which is where fully insured plans lose money anyway: people billed after they left, tiers that were never updated, dependents past the age limit.
Do we have to change brokers to have this done?
No. A review needs a one-page authorization letting the carrier release your own information. It does not change who represents you. Your current broker keeps the account, and the findings come to you directly. What you do with them is a separate decision.
How often should this run?
On a cadence rather than once a year. Correction windows close on a rolling basis, so a quarterly reconciliation recovers money that an annual audit finds too late. It also catches a setup error in its first quarter instead of its fourth.
Is this a sample, or every claim?
Every claim. A sampled audit reads a few hundred records and reports the patterns, which is useful for fixing process and no use at all against the single large error that was not in the sample. The exceptions that pay for the work are the ones a sample is least likely to catch.
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.
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