There are two generally accepted approaches for auditing claims: 100-percent claims audit and stratified random sample audit. Based on your objectives, Truven Health Analytics can fully support either method.
100-Percent Claims Audit
Our 100-percent claims audit tests all claims for modeled attributes, such as eligibility, plan design features, compliance with an administrator’s policies and procedures, and industry practices. This 100-percent claims audit approach identifies hard-to-discover, systemic processing errors and potential overpayment recoveries.
Stratified Random Sample Audit
This random-sample approach is an end-to-end claims processing audit used to measure an administrator’s claims processing accuracy and timeliness against performance guarantees, industry practices, and marketplace standards. Results from the sample can be extrapolated to the full claims population and can be expressed in statistical terms.