Audit Department

An independent audit is one way to gain assurance regarding the TPA’s internal control environment. The audit may include detailed tests of claims processed during a particular period of time, data analysis to identify trends and irregularities, and contract analysis.

TPAs also provide services that are usually financial in nature such as processing and pricing of claims, and claims payment.

Duties and responsibilities

Audit

Receive statement from healthcare providers or from adherents for refund.
Audit all type of claims (Refund, emergency, hot and cold cases and ambulatory).
Check claims eligibility.
Assure the completeness of the medical record, bill and documents related.
Ensure that medical treatment given by providers is necessary, appropriate and cost effective.
Process the audit in accordance with the policy wordings and HCP’s contract.
Up-date estimated cost, final diagnosis or case type related to limitation and exclusion
Ensure that the reimbursement request is complete and accurate.
Proceed the audit for refund claims as per set guidelines.
Assure quality control and reporting for any fraud.
Make sure that clients are handled with high efficiency.
Liaise closely deviations of treatment and medical care as per policy terms and conditions and fraud detection.
Implement strategical cost containment measures.

Audit Department

Audit Department

Duties and responsibilities

Audit

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