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Claim Audit Service

The best way to fully evaluate the quality of claims administration and to determine if claim processing mistakes are costing the plan precious benefit dollars, is through the performance of a comprehensive claims administration audit by an independent, experienced audit firm. Trilogy has the skills and tools to be that experienced, independent audit firm.

Trilogy has audited over $3.2 billion dollars in claim payments issued on behalf of millions of covered lives during the most recent ten year period.
Self-Funded Claim Administration Audit
Plan sponsors who provide self-funded benefits are assuming a significant financial risk. Whether the plan self-administers or retains the services of a third party administrator, incorrectly processed claims can be costly to the plan. To ensure self-funded claims are processed accurately and in accordance with the provisions of the plan document, it is necessary to perform a comprehensive claims audit. Trilogy provides claim audit services to self-funded corporate employers, government benefit plans and Taft-Hartley plans, for an independent, objective assessment of claims administration quality. Claim audit projects can be customized to meet the objectives of a self-administered plan or to evaluate the claims processing quality of an external claims payer.

Claim audits performed by Trilogy ensure the plan’s compliance with The Sarbanes Oxley Act of 2002 and assist the plan in meeting its fiduciary responsibilities. Additionally, claim audit reports completed by Trilogy will identify incorrectly processed claims, explain error trends, and provide recommendations for the prevention of similar mistakes going forward. The report is written in any easy to understand format and may be used as a tool for the development of an action plan to improve the quality of overall claims administration and reduce the incidence of costly mistakes to the plan.

Trilogy maintains a client retention rate exceeding 95% and multiple clients have retained the services of Trilogy for over 15 years. Trilogy works closely with its clients and their claim payers to improve the ongoing quality of claims administration through a process of retrospective review and evaluation. Annual claim administration audits performed by Trilogy include the evaluation of the claims payer in resolving ongoing issues including the monitoring and collection of overpaid claims. This type of audit methodology results in 100% of the amount of overpayment identified being returned to the client without the deduction of a “contingency” fee by the audit vendor.
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Claim Administration Operational Reviews
Claim administration operational reviews can be performed in conjunction with a comprehensive claims administration audit or independent of a comprehensive claims administration audit. Trilogy’s operational reviews evaluate the claims payer’s procedures and processes in the following areas:
  • Eligibility,
  • Claims Systems,
  • Cost Containment,
  • Fraud Control,
  • Claim Turnaround Time,
  • Quality Standards,
  • Coordination of Benefits Investigation, and
  • Subrogation/Right of Recovery.
To test the administrator’s adherence to its stated procedures and processes, Trilogy can also review a small number of claims. Claims can be selected on a focused basis, i.e., high dollar claims, out of network claims, claims with benefits paid directly to the member, claims for dependent spouse’s, etc. The number and type of claims selected will be based on the plan’s objectives and budget.

Operational reviews performed by Trilogy can assist a plan sponsor in determining if its claims administrator is meeting industry benchmarks in the above areas. Additionally, Trilogy will highlight processes and procedures which require improvement to contain costs to the plan and better meet the plan sponsor’s benefit objectives.
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Performance Guarantee Audits
If a plan sponsor has contracted claim administration performance guarantees with its claims payer, Trilogy can evaluate the performance guarantees and perform a claim audit to monitor performance against guarantees. Frequently, the terms of the contract will require a particular type or scope of claim audit be performed to evaluate claim administration quality and measure performance against guarantees. Trilogy benefit professionals are experienced in working with third party administrators and conventional ASO carriers to complete performance guarantee claim audit projects in compliance with any contracted requirements. Performance of claim audits in accordance with the contracted requirements will ensure the audit findings are accepted by the claims payer and result in the timely payment of penalties.
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Electronic Plan Audit Capabilities

Coming Soon!

Where Has Trilogy Audited?

See map below for a partial list:

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