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Internal Audits

MIS, Inc. conducts internal audits for Third Party Administrators by reviewing claims that are manually adjudicated as well as auto adjudicated by the claims system.  We provide a service by ensuring the TPA that the information is programmed correctly into the claims system and the examiners are providing quality work.  Our services also afford a comfort level to the TPA clients by providing an outside source to audit the claims.  The audits are certified by MIS, Inc. and are made available to the TPA client groups.  Because of our vast experience in conducting external audits for our clients, MIS, Inc. is able to advise the TPA of items that should be addressed prior to the review by the outside audit firm.

EXTernal Audits

As the costs of medical care continue to rise, employers and their consultants are increasingly involved in managing employee benefit programs. This involvement not only changes how benefits are obtained but also impacts how they are funded. Employers are now shouldering a larger portion of the risk, prompting the emergence of numerous managed care health products aimed at controlling healthcare expenditures. However, the effectiveness of these initiatives can be compromised if the integrity of the underlying data isn't rigorously reviewed beforehand.


This is where our auditing services step in as the solution. By ensuring the accuracy and reliability of fundamental data, we establish the foundation necessary for informed decision-making, ultimately maximizing the effectiveness of managed care efforts and helping employers mitigate rising healthcare cost.

ppo comparison

Due to the high competition with Preferred Provider Organizations (PPO), self-funded employers are relying on the information submitted by proposals from the Third Party Administrators/PPO.


Our service provides the employer with a unique look at what the discounts would be for local providers and hospitals in their area if they were to award the contract to the Third Party Administrator(TPA)/Insurance Company.


This process makes the decision easier for our client prior to awarding the contract to the TPA/Insurance Company.

Internal Audits

Types of Internal Audits

  • Random daily audits of 2%-5% of claims processed per examiner

  • Performance Guarantee audits every month or through quarterly reporting

  • New examiner audits at 100% for the first 30 days      


  • New group audits in which the plan document is reviewed against the system programming

  • High Dollar payment audits

  • Audits for new system implementation

  • Focus audits by request

  • Disability audits

We schedule weekly conference calls to discuss any errors detected during the previous week and we offer suggestions to help with examiner performance.

A database is provided to all clients in which all audited claims are listed with the errors detected.  The database is capable of generating reports by examiner, group, location or supervisor.  Other reports are available by request.

Our clients have stated that their outside audits have improved dramatically due our internal audits addressing the errors on a daily basis.

External Audits

External Audit Process

Office Procedure Overview

The initial phase of the audit includes conducting an on-site interview to determine the quantity and qualifications of personnel engaged in claim processing.

Targeted Claims Sample

A selected random sample of claims from a specific period is reviewed by our auditors. This portion of the audit appraises the payment and claims system.

Exit Review & Final Report

An exit meeting is scheduled with the claims director to present and clarify our findings, and ensure the accuracy of our results. The final report is formulated and forwarded to the client containing the following information:

• A description and appraisal of the on-site review and general narrative.

• Itemization of results with detailed explanations.

• A complete statistical summary.

About the Sample Claim Selection

We select a random sample of 250 claims processed during the target period to evaluate adherence to the plan's provisions. This sample is drawn from a list of claims provided by the client


Claims System Review Objectives

• Discuss the claims system and observe a demonstration of the system.

• Discuss the claims adjudication capabilities of the system with the client and document its functions and processes.

Claims Office Review

By engaging in discussions with claims administration personnel and observing claim office workflow and operations, we acquire and document an understanding of claim office procedures. Subsequently, we engage with claims personnel to explore the procedures implemented for quality control in claims processing and payment.

Claims Adjudication Process

• Define a claim sample item as an Explanation of Benefits (EOB).

• Compare the documentation for the sample of claims selected for accuracy and adherence to the provisions of the plan.

• Complete a claim review worksheet for each claim sample


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