Configuring a random audit

Random audits are configured in the portal by selecting Configuration->Random audit.

The landing page to configure the audits is made available to the user. Each type of audit has its own tab on this page. To create a new audit for each type, select Add new. To modify an existing audit, select the gear icon and to delete an existing audit, select the trashcan. Multiple audits can exist for the same type. For example, for the provider approved amount, a client may configure 100% of all claims to set for a value greater than $500,000 and 10% of all claims set for a value greater than $250,000.

Note: only active audits can be deleted. Once deleted, they will have a status of Inactive.

The following table shows the fields in the audit configuration list:

Selecting add new or update will present the following screen. The only difference between an update and add new is that the key field in an update will be read-only.

The key record for the audit will contain the key. In the example above, this is a member contract ID. The random audits use a threshold value in the calculations. This identifies the percentage of claims that will be selected for audit. Each time a claim is processed, Smart Claims Engine generates a random number from 0 to 99. This value is compared to the percentage and if the random number is less than the value of the threshold, the claim will be 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. When a decimal place is used, the random number generator will increase the number to be sampled.

Example configurations:

• 10% is entered as the threshold
  • The random number generated will be between 0 and 99
  • If the number returned is less than 10, then the audit will set.
  • If the number returned is 10 or greater, the claim will pass.
• 0.5% is entered as the threshold
  • The random number generated will be between 0 and 999
  • If the number returned is less than 5, then the audit will set.
  • If the number returned is 5 or greater, the claim will pass.
• 0.02% is entered as the threshold
  • The random number generated will be between 0 and 9999
  • If the number returned is less than 2, then the audit will set.
  • If the number returned is 2 or greater, the claim will pass.

Comments are required, and once configured, the audit can be sent for approval by selecting Save. The new or updated audit will then be displayed in the list with an approval status of Pending-new or Pending-update. If the audit is new, then the status will be inactive. If the audit is existing, then the status will be active, and the updated threshold will show the new value.

Note: if the random audits module sets and event code, the orchestration runs the event review module again to appropriately handle the event code.

Note: the random audits module can be placed in any location in the process flow, but if an audit for the approved amount is required, then the module will need to be located after the Process Updates module (SPU).

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, as well as random checks of examiners’ work.

Random number

The random number enables a random number of claims to be selected for audit.

Provider approved amount

The provider approved amount enables claims to be selected for audit based on the approved amount on the claim. This can be used to audit claims which have large check payments going out.