Configuring a random audit
To configure a random audit:
- In the Business Analyst portal, click Random Audit on the Left navigation bar
under Configuration.
The Random audits screen appears.
- Click a tab to select the random audit category.
- To add a new random audit, click the Add new button.
The Add New Record dialog box appears (for example).
- Based on the audit type, described below, complete the information in the fields.
Each configuration uses a threshold value in the calculations. This identifies the percentage of claims that will be selected. Smart Claims Engine uses a random number generator (0-99) to identify whether a claim is selected and uses that random number to compare with the percentage. If the random number is less than the value of the threshold, then the claim is selected for audit. If a threshold is set to 100, then all claims are selected. If a threshold is set to 0, then no claim is selected. Decimals can also be entered, so 0.5% or 0.01% of all claims can be selected if needed.
- Click Save.
Once a configuration has been updated, it is sent for approval. If a new record or an update is not needed, click Cancel.
- Click Close to dismiss the Message dialog box.
The dialog box identifies the work object ID associated with the approval of the new random audit.
Once approved, the audit is classified as “Active”.
Items waiting for approval have a status of “Sent For Approval”.
Claim amount
The claims amount uses a minimum amount to select claims for audit. The minimum amount must be equal to or less than the billed amount on the claim for it to be selected for audit.
Claim type
The claim type selects claims of a certain type for audit.
Contract number
The Contract ID allows employers with specific contracts to be selected for audit. This may occur to validate that claims are paid correctly based on a new contract’s benefit plan.
Member
The Member ID allows claims for a specific member to be selected for audit. This can be used to check for member fraud.
Billing provider
The Billing Provider ID allows claims for a specific billing providers tax ID to be selected for audit. This can be used to check for provider fraud or review claims for a new provider who has recently been onboarded.
Examiner
The Examiner ID allows claims that have been processed by a specific examiner to be selected for audit. This allows for training and validation for new examiners and also random checks of examiners’ work.
Random number
The random number enables a random number of claims to be selected for audit.
Provider paid amount
The Provider paid amount enables a claim to be selected for audit based on the provider paid amount on the claim. This can be used to audit claims which have large check payments going out.
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