Claim audits and file scoring.

Random-sample claim audits that score how a claims operation is performing against its own standards and the industry’s.

Reserve adequacy studies Claim audits and file scoring Estate claim adjudication and audits

About this practice area

Scoring the file.

A claim audit draws a sample of files, usually at random, and scores each one against a consistent set of tests: whether coverage was confirmed, contact & investigation were timely, the reserve was set and revised properly, payments were accurate and supported, and the file documents what was done and why.

Scored this way, individual findings add up to a measure of the operation: error rates, payment accuracy, documentation quality, and compliance with the company’s guidelines and the applicable regulations. Audits are performed for carriers, for receivers examining an insolvent insurer’s payments, and as the factual basis for expert opinions in litigation.

A drawer of claim files with five drawn at random into a solid audit tray, one of them flagged amber, closed with one solid mark

Engagements

File by file.

Audits for receivers, carriers, and counsel, with score sheets that aggregate the results.

Testifying expert · Report, Deposition, Trial

Three-month trial over a failed insurer’s directors and outside auditor

$2Bplea in the case

265claim files scored

800+page report

Receiver’s expert

TPA suit over a workers compensation deductible recovery: random 52-file audit

100files reviewed, 52 selected at random

100+page rebuttal report

379citations, 23 exhibits

Defense of TPAs, agencies, and counsel

Claim audit of an insolvent carrier’s property losses

2opinion reports

Randomsample of the claim population

Estate claims and audits

Other matters

Homeowner claim-file audit in a TPA service-agreement disputeTestifyingDefense of TPAs, agencies, and counselRead moreShow less

Retained by counsel representing a third-party administrator being sued for alleged breaches of a claim service agreement. This assignment included completing an audit of homeowner’s claim files. GIC repeated the TPA’s internal quality control audit and verified their file scoring and conclusory report. This portion of the audit reviewed 112 files. Deliverables included an expert’s report, rebuttal report, and accompanying claim file score sheets. Case was dismissed after opposing expert was stricken.

Also listed under: Defense of TPAs, Agencies, and Counsel

Review of a claims department’s staffing, procedures, and settlement practicesTestifyingCarrier claims-practice reviewsRead moreShow less

Completed reviews and expert reports assessing propriety of Subject Company’s claim department’s staffing, claims handling policies & procedures, and overall fairness of Company’s claim settlement practices.

Also listed under: Fair claims practices and standards of care · Carrier claims-practice reviews & audits

Reserve adequacy studies

Whether the reserves held match what the files support, case by case and in total.

View Reserve adequacy studies →

Estate claim adjudication and audits

Evaluating, adjudicating, and auditing the claims filed against an insurer in liquidation.

View Estate claim adjudication and audits →