What is a Claims Audit?
Claims audit may refer to reviewing the claims submitted by a policyholder to an insurance company to verify their accuracy and completeness. During a claims audit, the insurer will review the records and documents submitted by the policyholder to ensure that the claims align with the terms and conditions of the policy agreement.
Claims Audit in More Detail
A claims audit aims to identify any discrepancies or inaccuracies in the documentation and records that the policyholder may have submitted. This process helps the insurer verify that the submitted claims are eligible for reimbursement or payment. The insurer may also use the audit to identify any potential fraud or abuse of the policy or process.
The claims audit process can be conducted in various ways, such as in-house by the insurer or an external auditing firm. Sometimes, the process may involve the insurer obtaining additional information from the policyholder. The audit process may also involve the review of the policy contract and other related documents.
The results of a claims audit can determine the eligibility of the claim for payment, as well as the amount of reimbursement or payment. Additionally, the insurer may use the results of the audit to determine any corrective action that may be necessary.
Therefore, a Claims Audit is a process of reviewing and verifying the accuracy and completeness of claims submitted by a policyholder to an insurance company. The audit’s goal is to ensure that the claims align with the policy agreement’s terms and conditions and to identify any potential fraud or abuse of the policy or process. The audit results can determine the eligibility of the claim for payment, as well as the amount of reimbursement or compensation due.
Subscribe to The Shield
A bite-sized newsletter outlining industry insights & best practices for high-growth companies.