title: Health plan auditing: 100-percent-of-claims vs. random-sample audits.
abstract: The objective of this study was to examine the relative efficacy of two different methodologies for auditing self-funded medical claim expenses: 100-percent-of-claims auditing versus random-sampling auditing. Multiple data sets of claim errors or 'exceptions' from two Fortune-100 corporations were analysed and compared to 100 simulated audits of 300- and 400-claim random samples. Random-sample simulations failed to identify a significant number and amount of the errors that ranged from $200,000 to $750,000. These results suggest that health plan expenses of corporations could be significantly reduced if they audited 100% of claims and embraced a zero-defect approach.
authors.affiliation: Pharmaceutical & Healthcare Marketing Department, Haub School of Business, Saint Joseph's University, 5600 City Avenue, Philadelphia, PA 19131 USA. sillup@sju.edu
authors.forename: George P
authors.initials: GP
authors.lastname: Sillup
authors.forename: Ronald K
authors.initials: RK
authors.lastname: Klimberg
mesh_terms: D057286:Electronic Health Records; D005375:Financial Audit / Q000379:methods*; D005102:Health Expenditures; D006801:Humans; D007344:Insurance Claim Reporting / Q000592:standards*; D007345:Insurance Claim Review; D011785:Quality Assurance, Health Care; D012051:Reimbursement Mechanisms; D014481:United States