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Self-Funded Insurance Plan Audits

Claims Model

At MCM CPAs & Advisors, we think beyond your bottom line. We provide our clients with services that reach far beyond the traditional tax and assurance offerings of other firms. We do this by leveraging high-impact expertise in an array of industries, technologies and operations. We identify opportunities, and anticipate challenges, from all angles, for all of our clients.

For many clients, self-funding its insurance plan has been a successful way to mitigate the impact of rising healthcare costs. Self-funding brings on additional fiducial responsibilities. It is imperative to your bottom line to understand the direct correlation between unnecessary and inaccurate claims. If a third party administrator (TPA) inaccurately processes just 2% of claims, it equates to a $200,000 overpayment for a plan with $10 million in annual claims. MCM’s processing audits have historically identified a 2%-5% error rate.

MCM is one of the only Top 100 accounting firms with the expertise to perform claims accuracy and performance audits. Our national practice has successfully performed more than 300 medical, life, disability, dental, vision, FSA, pharmacy and workers’ compensation claim audits. Our accounting professionals also bring their unique background to the process, evaluating not only the present issues, but also the claims payment and process controls.


MCM highly recommends all self-funded plans with more than 250 covered lives consider a claims audit if any of the following is needed or present:

  • Validation of your TPA’s performance to contractual and industry standards
  • Identification and mitigation of unnecessary healthcare spending
  • Verification of processing accuracy for performance guarantees with your TPA
  • Transitioned to a new TPA or significant changes to the benefits
  • Supplement your processes by adding additional scrutiny of these significant costs
  • Desire for increased governance and monitoring of your fiduciary responsibilities
  • Access to national expertise without incurring the costs of employment


MCM provides an objective, independent claims audit focused on your needs. Our methodology consists of evaluating the design of controls, testing the major claims processing cycles, determining the accuracy of payments and identifying any value savings recommendations. Our risk-based approach is designed with management to customize a specific plan for your organization. Our experience encourages the following testing procedures and assessments:

  • Operations assessment
  • Random claims sample
  • Duplicate payments sample audit
  • High dollar claim validation
  • Stop loss insurance recoverable verification
  • Targeted sampling of identified high-risk areas
  • Key process interviews with the claims administrators

To see if our services are a good fit for you, complete a self-assessment here or contact Sean Ennis, CPA, MBA 502.882.4448.

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Personnel Profiling joins MCM

Effective July 1, 2014, Personnel Profiling, Inc. has joined the team at Mountjoy Chilton Medley, Kentucky’s largest CPA & advisory firm. With MCM, we’ll continue to offer the same top notch HR assessments, services and tools, now coupled with a greater breadth of in-demand expertise and services. You can now find the PPI main office and staff at MCM’s downtown Louisville headquarters.

Read About The Merger Continue to MCM's Website