What Is a Health Claim Audit?

A health claim audit is an independent review of medical, dental, vision, or other health-related claims paid by an employee benefit plan. Conducted by a licensed CPA firm or specialized auditor, it verifies that claims were processed accurately, paid to eligible participants, and disbursed in accordance with the plan document, applicable contracts, and federal regulations — including ERISA and Department of Labor (DOL) requirements.

Examples of Health Claim Audits

• Random Sample Claim Audit — A statistically representative sample of paid claims is selected and reviewed to identify billing errors, duplicate payments, or improper reimbursements across the plan.
• 100% Claim Audit — Every claim paid within a defined period is examined in full, providing a comprehensive picture of plan accuracy and potential overpayments or fraud.
• Eligibility Audit — Verifies that all individuals receiving benefits — including dependents — are properly enrolled and meet the plan’s eligibility requirements at the time of the claim.
• Provider Billing Audit — Reviews charges submitted by healthcare providers to confirm they align with contracted rates, coding standards, and plan allowances.
• Third-Party Administrator (TPA) Audit — Evaluates the performance and accuracy of the TPA responsible for processing claims on behalf of the plan, ensuring compliance with the administrative services agreement.