Why Claim Audits Are More Valuable than Ever

February 14, 2024

By Joe DiBella, Executive Partner, National Employee Benefits Practice Leader

As healthcare costs continue to rise, claims audits remain an essential tool in employers’ toolbox.

Health plans are bracing for a significant uptick in costs in 2024. Employers project a median health care cost increase of 7 percent next year, according to the International Foundation of Employee Benefit Plans (IFEBP).

Several realities of today’s healthcare landscape are driving this increase. Employers identified chronic conditions, catastrophic claims, and rising drug costs as the leading contributors. At the same time, evolving models of care and new technologies are driving dramatic shifts in treatment and administration at providers of all kinds.

Claims audits can help employer health plans stay one step ahead of shifting practices while ensuring costs and pricing remain accurate and efficient. In fact, any employer that funds its plan with employee payroll contributions has a fiduciary responsibility to make certain the expenses and spending associated with the plan are correct.

Claim audits are a crucial tool in satisfying that fiduciary responsibility – and keeping costs in check.

Here’s a closer look at how claims audits can be utilized given the realities of today’s healthcare landscape.

New Technologies and Process Updates Require Regular Audits
Third party administrators (TPAs) and health plans regularly update their systems and technologies, and today those updates are faster and more far-reaching than ever. With each update and recode of benefits and procedures, it’s incumbent on group health plans and sponsors to ensure their program has been recoded correctly. Checking for accuracy on plan details including copays, out-of-pocket maximums, and more is essential.

For many TPAs and carriers, technology updates and programming changes are happening all the time. Determining an audit schedule that delivers a meaningful return by ensuring accuracy is important. For particularly far-reaching updates, a preimplantation audit that allows for a review of a new system or protocols before it goes live can help identify and correct issues before they impact claims and costs.

Employers and plans should look to maximize the impact of audits by ensuring that any audit findings resulting in inaccurate claims or spending waste prompt investigations into similar claims.

Claims with similar details or those occurring during the same time period may also have been processed incorrectly.

Catastrophic Claims Demand Special Attention
Nearly one in five employers identified catastrophic claims as the primary reason for the cost increases in 2024. It’s not uncommon for employers to see multiple $500,000 or $1 million claims among their population.

With the advent of super large claims comes a need to evaluate them and make sure the costs are delivering the most effective and efficient care possible.

Audits of these claims can benefit from a closer evaluation from both an administrative and clinical perspective. An administrative review can help with factors like ensuring specialty care and treatments are accurately coded and deductibles are being handled correctly. On the clinical side, the audit can ensure the efficacy of treatment plans and identify improvement opportunities that benefit patient, provider, and plan sponsor. For example, a patient diagnosed with cancer may trigger a catastrophic claim audit. This patient may be receiving chemotherapy at a hospital or outpatient setting. An audit may identify that transitioning that treatment to the patient’s home with home health assistance could reduce costs while also allowing the patient to receive care in the comfort of their home without the added travel time and cost.

In these instances, it’s important to call out that audit findings and actions should not have a detrimental impact on the patient’s care experience. Employers should prioritize collaboration with carriers and providers to ensure updates that are mutually beneficial for all parties.

The CSB Advantage
At Conner Strong & Buckelew, our approach to claims audits delivers deeper findings and more actionable insights to help control costs and ensure effective and efficient care. ClaimCheck, our proprietary audit tool for large and catastrophic claims, delivers peace of mind for self-funded employers. This unique employee benefits claims screening process ensures large and catastrophic claims are being properly managed by the complex healthcare system, adjudicated pursuant to the plan of benefits, and paid properly.

With ClaimCheck, a claim will be flagged for review by a Conner Strong & Buckelew clinical nurse once it reaches either $100,000 or 50 percent of the client’s stop loss deductible, whichever comes first. The claim is reviewed for eligibility, care management and ongoing monitoring to ensure all needed care management oversight is in place. Cases are reviewed and remain open until the treatment is concluded or the client receives applicable stop loss payment. Even after payments are made, claims are monitored for ongoing appropriateness. Any claim more than $200,000 automatically goes through a case audit of the carrier’s adjudication accuracy of the claim to ensure all claims were paid properly.

With traditional audits, Conner Strong & Buckelew delivers greater value through our scale and our commitment to exceptional service and superior outcomes. We utilize robust samples in our auditing to ensure an accurate representation of a plan and its claims. If we find claims that were paid incorrectly, we require that the TPA or carrier pull claims with similar characteristics to ensure accuracy. From there, we conduct an impact analysis to quantify other challenges or errors that could result from this audit finding. And while other partners end the relationship after delivering the audit results, our team works with clients until the end, when claims are accurately paid and systems, policies, and procedures have been corrected.

At the same time, our scale and expertise offer an edge in developing audit samples and identifying potential issues. We utilize our vast experience of conducting dozens of audits a year to apply lessons learned to our work – all without compromising proprietary plan details or patient privacy.

The result is a more effective and impactful audit that delivers actionable results for employers and plans. From systems updates to catastrophic claims, Conner Strong & Buckelew serves as a true partner in health plan audits that can drive better health outcomes and protect a company’s bottom line.


Click Here for a Printable Download


Claims Management

Practice Leader

Joseph M. DiBella

Executive Partner, National Employee Benefits Practice Leader

More than 27 years of employee benefits experience

Previously led national and large account business for Horizon Blue Cross Blue Shield of New Jersey