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

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

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


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.

[Indexed for MEDLINE]

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