Format

Send to

Choose Destination
Int J Electron Healthc. 2011;6(1):47-61.

Health plan auditing: 100-percent-of-claims vs. random-sample audits.

Author information

1
Pharmaceutical & Healthcare Marketing Department, Haub School of Business, Saint Joseph's University, 5600 City Avenue, Philadelphia, PA 19131 USA. sillup@sju.edu

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.

PMID:
21406351
DOI:
10.1504/IJEH.2011.039058
[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Atypon
Loading ...
Support Center