Health Insurance Claims Audits: The Challenges of Volume and Complexity

Health insurers receive many claims, in a variety of formats. Claims processors must be diligent and mindful of the associated risks when processing claims. This includes verifying that coverage exists, determining whether the claim is for a covered benefit, determining the proper amount to pay and then paying the appropriate party.

Health insurers depend heavily on automated systems, whether in-house or through a third-party provider, to adequately process the high volume of claims. Auditing the claims processes requires a thorough understanding of a company’s related risks, systems and approaches.