Audit Process

The claims audit will address five distinct areas:

  • Claims System, including claims paying processes, internal audit protocol, and fraud/abuse prevention and detection capabilities and resources
  • Adherence to the Benefits Contract (identifying misalignments between the claims system and the policy/contract),
  • Claims Adjudication Processes and Error Rate, through substantive testing of actual claims processed under the plan
  • Testing Plan Eligibility, including plan enrolment, record keeping and administrative processes relating to employee and dependent information
  • Financial Accounting, including an audit of paid claims and stop loss claims, expenses, taxes, and HST, as reported in monthly ASO statements