The SCE contains a configuration and module (SRA) to support the random auditing of claims that are processed through the engine. The system will set random audits, when configured for a wide variety of reasons. Each audit contains its own configuration supporting the percentage of claims that will be identified as well as key attributes.
The random audit module will set the following event codes:
|Random audit - billing provider
|This claim is selected for audit based on the billing provider.
|Random audit – member
|This claim is selected for audit based on the member ID.
|Random audit - claim type
|This claim is selected for audit based on the claim type.
|Random audit – contract
|This claim is selected for audit based on the contract ID number.
|Random audit - claim amount
|This claim is selected for audit based on the claim billed amount.
|This claim is selected for audit based on a random selection.
|Random audit – examiner
|This claim is selected for audit based on the claim examiner keying the claim or resolving any event code on the claim.
|Random audit - approved amount
|This claim is selected for audit based on the approved amount.
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:
This is the key for the audit being applied. Each audit is detailed with the key information in the sections below. An example is Min. claim billed amount.
Note: the same audit key cannot be repeated on the table. For example: Member MB2015072411 cannot have a row for a threshold of 100% and another for 10%. An error will be displayed if a new entry is attempted with an existing key.
|The percentage of claims that will be selected for audit. 100 will be all claims and 0 will be none. Decimal places are available, which can be used to decrease the number available for audit. For example, 0.001%
|Updated threshold (%)
|If an update is pending, this column indicates the new threshold.
|If the audit is active or inactive
|If the audit is approved, pending-new, pending-update or pending-delete
|Last modified on
|The date the audit was last modified.
|The ID of the user creating or updating the audit.
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.
- 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).
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.
The claim type selects claims of a certain type for audit.
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.
The member ID allows claims for a specific member to be selected for audit. This can be used to check for member fraud.
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.
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.
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.