What goes into conducting a healthcare claims audit?

For self-insured employers — and the brokers, consultants, and third-party administrators who support them — the final audit report is often the most visible part of the process. It highlights findings, recoveries, and opportunities for improvement. But those results are built on a much larger effort happening behind the scenes.

From data validation and claims analysis to auditor review and client communication, healthcare claims audits require a coordinated process designed to uncover inaccuracies, strengthen compliance, and improve plan performance. The most effective audits combine technology, operational discipline, and human expertise to transform raw claims data into meaningful insights.

As Operations Manager at Healthcare Horizons, Brylee Trew helps oversee the workflows, collaboration, and quality standards that make these data-driven claims audits possible. In this conversation, she shares how Healthcare Horizons approaches audit operations, why the company reviews 100% of claims, and what happens behind the scenes to help clients achieve better outcomes.

Brylee Trew: One of our biggest differentiators is how closely our teams work together. Our auditors, data analysts, operations staff, and client stakeholders collaborate from day one rather than working in separate silos.

Operationally, we rely on tightly defined workflows and strict quality checkpoints, but we place an equal emphasis on peer review. This structure allows us to combine cutting-edge technology with deep healthcare claims expertise. Our data team analyzes massive claim populations to highlight potential risk, while our auditors apply their real-world experience to validate those findings and uncover nuances that automated systems alone would miss.

That balance of technology, process, and human expertise allows us to efficiently manage large volumes of claims while maintaining the level of precision our clients expect. 

At the end of the day, our goal isn’t simply to check a box or point out errors. It’s to uncover meaningful opportunities that help clients strengthen their plan performance and achieve long-term savings.

Brylee: When people hear that we review 100% of claims, the first question is always, “How is that even possible?”

The answer is technology combined with experienced auditors. We analyze the entire claims population from the start rather than pulling a small random sample and hoping it tells the whole story. This macro-view allows us to spot broad patterns, subtle anomalies, and areas of potential risk that traditional sampling can easily miss.

Once the data team flags potential issues, our auditors step in to review the supporting documentation and determine if there’s a real problem. That’s the part you can’t automate. It requires real-world judgment and a deep grasp of complex healthcare claims administration. I often describe it as technology helping us find where to look, and people determining what the data actually means.

Working from the full picture gives clients greater confidence in the results.

Brylee: Every audit begins with data. Before any analysis takes place, our team validates the claims files, eligibility data, and plan documentation to ensure the information is complete and usable.

Once validated, we analyze the claims population to identify potential risk areas and trends. Our auditors then perform detailed claim-level reviews, validate findings, and examine how claims were processed against plan provisions and administrative requirements.

Throughout the engagement, we maintain regular, transparent communication with the client so they always know where we are in the process, what we’re seeing, and what to expect next.

The final phase is reporting — we deliver financial impact analyses, root-cause insights, and recommendations to prevent future leakage.

Brylee: Spotting an error tells you what happened. Understanding the root cause tells you why it happened and, more importantly, how to stop it from happening again.

When we identify an issue, we look beyond the individual claim to find the underlying driver. Is it a flawed contract interpretation? A system configuration issue? A broken claims processing workflow? Or just a communication gap between vendors? We work backward from the finding to understand what’s driving it.

Because we review the full claims population, we can see the broader trends driving these issues. This allows us to give clients recommendations that go beyond recoveries and help them address underlying issues to reduce future risk.

Often, the greatest value comes after an error is identified. That’s where we have an opportunity to help clients address the underlying issue and improve long-term plan performance.

Brylee: We don’t treat an audit as a reporting exercise. We treat it like an investigation.

Many organizations can generate reports, dashboards, and automated alerts. Those tools have merit, but they don’t explain the context behind the data or what should be done about it. 

Our team spends time validating findings, reviewing documentation, and truly understanding our clients’ plan operations. We ask questions, challenge assumptions, and dig deeper when something doesn’t look right.

Healthcare claims are rarely as straightforward as they appear on the surface. Plan provisions and operational context matter. Ultimately, clients don’t need more data. They need clarity. 

By combining advanced analytics with experienced human review, we’re able to provide findings that are accurate, actionable, and grounded in a deeper understanding of how the plan is actually performing.

Brylee: I see how our internal collaboration contributes to successful outcomes every day.

A common example involves our data analysts identifying a pattern within a claims dataset that warrants further investigation. They hand it off to our auditors, who investigate the issue, validate the findings, and determine whether there is a legitimate recovery opportunity or process concern.

From there, our client services team communicates those findings, answers questions, and helps stakeholders coordinate the next steps.

From an operations standpoint, my role is helping ensure those teams have the processes, communication channels, and support needed to work effectively together. That’s often what allows an isolated finding to become a meaningful opportunity for recovery, operational improvement, or long-term savings.

Brylee: The biggest misconception is that a healthcare claims audit is simply a matter of generating reports and identifying overpayments. In reality, a significant amount of work happens behind the scenes. Before a finding appears in a report, our teams have reviewed data, validated results, evaluated plan provisions, and ensured the finding is accurate and defensible.

Another misconception is that success is measured solely by the dollar amount recovered. Recoveries are certainly important, but they’re only part of the story. Many clients gain just as much value from understanding why issues occurred, identifying process improvements, and reducing the likelihood of future errors.

Healthcare claims audits begin with data, but meaningful results come from the people and processes behind the analysis. From validating claims and investigating root causes to communicating findings and supporting recovery efforts, successful audits depend on close collaboration across teams.

As Brylee’s insights demonstrate, effective healthcare claims audits are not simply about identifying errors. They are about combining technology, human expertise, and operational discipline to help organizations better understand plan performance and make more informed decisions.

Learn how Healthcare Horizons can bring clarity and accountability to your healthcare spending. 

Contact our team today.

About Healthcare Horizons™

Healthcare Horizons is a healthcare audit and advisory firm dedicated to protecting the financial integrity of employee benefit plans. As a trusted partner to employers, brokers, and payers, we conduct independent healthcare claims audits to identify overpayments, uncover systemic errors, and confirm that plan administration aligns with contractual terms.

Our investigative, root-cause methodology reviews 100% of claims at the transaction level, combining advanced algorithms with deep human expertise to detect discrepancies that automated systems often miss. As a trusted partner and strategic extension of employers, we translate findings into practical recommendations that help organizations recover funds, prevent recurring issues, and strengthen plan performance.