Medical Audit

At Healthcare Horizons, medical audits constitute the majority of the services we perform for our clients. We specialize in auditing 100% of claims to yield the most accurate and effective results. Upon request, or if contractual obligations require, we can also perform the audit by testing a random sampling of claims.

Our auditing medical claims process is straightforward and effective:

  1. Gather the data. We request general plan information from the client as well as claims and eligibility data from the third-party administrator (TPA).
  2. Analyze the data. We test for a wide range of errors based on a number of criteria (described below). This testing culminates with an on-site visit to the TPA.
  3. Determine root cause. We work with the TPA to identify the root cause for errors and make recommendations for process improvement.
  4. Reporting. We deliver a full report of claims in error as well as a written report of findings.


The following is a partial list of categories examined by Healthcare Horizons.

  • Eligibility
  • Medical coding accuracy
  • Benefit maximums
  • Excluded services
  • Surgical reductions
  • Inpatient readmissions
  • Patient responsibility (deductibles, copays, coinsurance)
  • Abusive billing or fraud
  • Duplicates
  • Consistency of contracted rates
  • Coordination of benefits


Upon completion of our testing, we deliver a detailed audit report that documents our findings, including the areas tested, and a full list of erroneous claims based on the findings of the audit. We will also identify root-cause issues and make recommendations for correction moving forward.

By going to great lengths to ensure that our medical audits are as thorough and accurate as possible, Healthcare Horizons has been able to recover millions of dollars in overpayments for our clients, as well as ensure long-term savings by correcting root-cause issues. To learn more about our medical audit services, contact us here.