Workers’ Compensation Claims Audits Services

The Vendor is required to provide workers’ compensation claims audits to provide an audit of the city’s indemnity and medical payments issued by its third-party administrator (TPA).
- Auditor shall conduct a fully electronic screening of claims of a targeted, random sample size of 350 claims per fiscal year to ensure 95% statistical confidence (+/- 5%) in key indicators.
- Auditor shall identify non-compliance with workers’ compensation rules and procedures and city regulations.
- Auditor shall provide bi-weekly reports detailing number of claims reviewed and overpayments, irregularities or issues identified at that point.
- Comprehensive report at the conclusion of the review, identifying overpayments, duplicate payments, payment irregularities, operational inefficiencies, and actionable recommendations.
- Auditor must provide a corrective action plan for all identified errors within 180 days of assignment.
- The auditor must be independent of the current TPA and maintain the confidentiality of phi and financial data.