Comprehensive Medical Claim Audits
We specialize in uncovering issues through comprehensive medical claims audits, including 100% Electronic Claims Reviews, Focused Claims Audits, Statistical Claims Audits, and Operational Reviews.
Understanding Claims Audit Types
Withum’s claims audits may consist of one or multiple individual service offerings aimed at achieving the plan sponsor’s objectives. These are customizable based on your goals and needs.
Have every claim meticulously reviewed for accuracy, contract adherence, and compliance.
The goal of 100% electronic claims reviews is to improve efficiency, accuracy, and consistency in claims processing while identify and addressing issues timely.
This is a comprehensive examination of an organization’s internal operations, processes, and procedures to assess their efficiency, effectiveness, and alignment with strategic goals and objectives.
The goal of the operational review of a third-party administrator or PBM’s claims administration process aims to ensure compliance with regulatory requirements and enhance member experience while:
- Identifying opportunities for process utilization
- Reducing costs
- Improving performance
This is a targeted examination of specific aspects or areas within a claims administration process. A focused audit concentrates on particular elements, such as a specific type of claim, a certain provider, timeframe, or a particular issue identified through previous audits.
The goal of a focused medical claims audit is to delve deeper into areas of potential risk, inefficiency, or non-compliance, allowing plan sponsors to address specific concerns, improve processes, and enhance overall claims administration effectiveness.
This is an audit that utilizes statistical sampling techniques to evaluate the accuarcy and compliance of healthcare claims processing. Instead of reviewing each claim individually, statistical sampling selects a representative sample within a defined populated based on predetermined criteria and analyzes it to draw conclusions.
The goal in a statistical claims audit is for plan sponsors to gain insights into the accuracy, efficiency, and compliance of the claims processing operations of its TPA or PBM, identifying areas for improvement, implement targeted interventions, and optimize overall claims management processes.
Here’s Why Partnering With Withum Makes a Difference
Comprehensive Review
We meticulously review every claim for accuracy, contract adherence, and compliance.
Trusted Expertise
Our seasoned professionals are experts in healthcare claims auditing, identifying discrepancies others miss.
Tailored Solutions
We customize our audit approach to fit your unique needs and challenges.
Cost Savings
By correcting errors and inefficiencies, our audits can lead to significant cost savings, allowing you to reinvest in your health benefits program.
Clear Reporting
We provide straightforward, actionable reports to empower informed decision-making.
Industry Leaders
As recognized thought leaders in healthcare, we drive best practices and innovation in claims auditing, keeping you ahead of the curve.
Client Testimonials
Collaborating with Withum proved instrumental in addressing our health plan's challenges. We were experiencing unexplained cost increases that raised concerns among our stakeholders. Withum not only helped us uncover the underlying reasons for these increases but also identified significant errors in the processing of our stop-loss coverage. Their expertise, meticulous approach, and dedication to delivering concrete results have positioned Withum as an invaluable partner. We appreciate their insights and highly recommend their services to any plan sponsor seeking clarity in the administration of their health plan.
Large privately held company
Why Withum?
Healthcare Claims Audit Services
Withum’s team of health plan advisors has worked with plan sponsors from medium to jumbo health plans for more than three decades, helping them address their responsibilities through a comprehensive suite of services and technology designed to mitigate operational and compliance risk. This goes beyond medical claims audits, from Fiduciary Oversight of a plan sponsor’s health plan and eligibility process reviews, to TPA or PBM compliance audits of contract terms and cybersecurity risk assessments.