Why is it so hard to audit claims?

What are the challenges you face with your current audit in your current audit environment.

A Frustrating Legacy Audit Tool.

A legacy home built audit environment that is built around someone’s version of audit requirements from five or ten years ago that today is unresponsive to evolving business needs, difficult to change, and expensive to support. Even better, you may have two or three stand-alone audit tools used for different audits.

2016 Audit Tool Features Added

Datamethod has added over 300 features a year to ClaimAuditor
for the past 4 years. We listen to and aggressively add the
features that our customers need to support their business
and audit needs. Quit chasing your internal IT department.

Audit Goals You Can't Seem to Achieve.

Why has accuracy not improved? What is holding you back? How much root cause and corrective action related information do you have in your current audit tool? If the answer is mostly “none” – then why would you expect to see an increase in payment accuracy?

Root Cause Analysis

Every error in ClaimAuditor yeilds three root causes.  Imagine how much easier it would be to address Copay Errors if you have detailed root causes for 20 of them.

A Focus on Errors and Bad News.

We found 42 financial errors last month and what became of those findings? Instead of being the tip of the spear for process improvement and corrective actions, audit is generally the bearer of ‘bad news’. Shouldn’t you be making sure that every audit finding becomes an improvement?

Attach a Corrective Action to Every Error

Errors are not the end point in ClaimAuditor — corrective actions are. Reporting audit performance for a team using ClaimAuditor is less about counting errors and more about managing and closing corrective actions. Corrective actions and the tools to manage them are what make ClaimAuditor a tool to improve quality — not just a tool to track it.

A Byzantine Audit Process.

What needs to happen to add audits or manage a rebuttal or to run a monthly cycle of accuracy reports for processors? There’s a good chance that less than 50% of your total audit process hours are hours spent actually auditing claims and not in some other manual audit support process. It’s even worse if you have more than one legacy audit tool.

Efficiency Loss on Your Legacy Audit Tool

How many extra steps does your Appeal/Rebuttal process require? How about your reporting and analytics processes? ClaimAuditor has over 2,000 feature releases since it first went live. Each release is aimed at a particular business challenge in the audit process — to make it more effective or efficient or both.

How We Can Help

300% ROI in Year 1.


Up and Running in 30 days.

Case Study: 100 Hours of Audit

In a typical claims operation, approximately two to five percent of all claims are audited. Across the entire audit process – all participants and all steps – how does 100 hours of effort break down into specific audit activities?

In a typical shop, the chart to the right breaks down 100 hours by audit task.

We have changed these ratios in three ways:

  • 1.Task Automation. Results reporting is fully automated. Every day, every audit reports itself. Claim allocation is also automatic.
  • 2.Task Efficiency. We frequently review each audit and administrative task performed both in ClaimAuditor and in the audit process to identify ways to make auditor and all roles using ClaimAuditor more productive.

  • 3.Task Resources. We overhauled our rebuttal/appeal process specifically to make is possible to manage appeals with more junior resources.

Data is loaded, samples are created — 9%
Claims are allocated — 3%
An application is maintained — 3%
Auditors Audit claims — 34%
Errors are assigned and managed — 10%
Errors are responded to — 11%
Appeals are heard and managed — 16%
Results are published and reported — 14%