12.28.16

What Makes Up a Comprehensive Healthcare Audit?

Self-funded medical healthcare claim auditsTake a good look around. Everyday objects are made up of more than just what meets the eye. When you look at a clock, for example, you only see the exterior. The outside is made of plastic, wood and glass, but underneath the display are many pieces working together. Without the oscillator, controller and power supply plugging away behind the scenes, the hands wouldn’t be tick-tocking along. Without all of the parts, you’d only be getting part of the package, and that clock? Well, it just wouldn’t work.

Much like a clock, medical health care claim audits have multiple components to them, too. Each audit component can be a separate entity, but with a CTI comprehensive claim audit, each piece works even better when combined together to give you a full picture of your health care plan and the administrator’s effectiveness. It’s the combination of these components along with our Continuous Quality Improvement that sets us apart.

As soon as we have converted and validated all of the data we’ve been provided, we begin one of two pre-audit components of our comprehensive claim audit. Think of these review components as the clock’s batteries or power supply. Without the these components, the audit just wouldn’t function correctly.

OPERATIONAL REVIEW

To begin the pre-audit process, we ask the administrator to fill out an operational review questionnaire. Using those responses, and our cutting edge technology, we evaluate everything — including all of the claim administration systems, staffing, and procedures they have in place. The verified and tested findings from this component help us identify potential problem areas within the operation, sometimes before an onsite visit is even made.

PLAN DOCUMENT REVIEW

Once we review your administrator’s operations, it’s time to take a look at all of the documentation. This is where more pre-audit information is gathered using an in-depth review of all plan documents and provisions — including the summary plan description, benefit handbook, and the administrator service agreement. This component of the process, allows our audit staff to become completely knowledgeable about the benefit plan provisions prior to audit.

RANDOM SAMPLE AUDIT

These next two components of a CTI audit run parallel to each other like the mechanisms inside the clock that make it tick. This is where a medical claim audit really gets going and digs deep into the claim administration. Random sample audits enable the benchmarking of claim administration quality and quantification of savings potential. Our random sample audits provide:

  • Meaningful metrics on seven key performance indicators
  • Benchmarking vs. best-in-practice
  • Problem identification and prioritization
  • Error identification by type and frequency
  • Illumination of costly and/or beneficial performance trends
  • Statistically-supported remedial action plans

100% ELECTRONIC SCREENING WITH TARGETED SAMPLING

It’s all in the details. During this component of our audit, we review and analyze every service line processed during the audit period. It is here where our electronic screening identifies any overpayments (or underpayments) and other costly system problems. CTI auditors analyze the findings in six proven risk control categories and perform targeted sampling to test suspected errors. This allows us to formulate potential solutions to remedy the issue(s) and repair any leaks complete with detailed listings of errors and suggestions from CTI’s expert audit team.    

It’s important to note that some audit firms only provide 100% electronic screening audits OR random sample audits. CTI routinely provides both as part of our comprehensive audit. 100% audits frequently are offered on a contingency basis. Despite the seeming appeal to this approach, contingency audits provide no incentive to identify errors or work with your administrator to fix them. As ultimately, fixing errors means less compensation for the audit firm.  At CTI, however, we believe that working side-by-side with the administrator we can provide a much better service to you by identifying and fixing any potential problems.

DATA ANALYTICS

After all of the clock’s components have worked together, the time is displayed on the face for all to see. And, just like that clock face, our suite of data analytics is designed to give you the results — in a clear, concise manner.

  • Provider Discount Analysis — Reports in and out-of-network provider utilization and savings
  • Preventive Care Service Compliance Review — Confirms compliance with coverage requirements under the Patient Protection and Affordable Care Act (PPACA)
  • Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiatives (NCCI) Review — Identifies savings potential from emulating CMS program edits
  • Electronic Eligibility Verification — Identifies ineligible claimants by cross matching employer and administrator data
  • J-Code Analysis — Analyzes medical/pharmacy specialty drug overlap and prevents duplicate of payments

Combining years of expertise, cutting-edge proprietary audit technology, and our pioneering passion, CTI can provide you with a comprehensive audit unlike any other in the industry.

So, what time is it? It's time to trust CTI with your ROI! To learn more about CTI's comprehensive medical claim audits with continuous quality improvement, feel free to contact us or click the graphic below.

medical claim audit case study