There is a growing trend among self-funded medical plans: an increased focus on claims audits. These audits are essential for ensuring accuracy, compliance, and operational efficiency. Let’s start with a quick refresher on the four main types:
- Medical Claims Audit – The most common type, focused on verifying the accuracy of medical claim payments.
- Focused Sample Audit – Targets specific areas of concern or high-risk claims for deeper review.
- Pre-Implementation Audit – Conducted before a new plan or TPA goes live to confirm readiness and alignment.
- Operations Review Audit – Evaluates the overall efficiency and compliance of the TPA’s processes.
While all four audits play an important role, one is gaining significant traction: the Pre-Implementation Audit. Here’s why it matters.
What Is a Pre-Implementation Audit?
Think of this audit as a test drive before the car hits the road. When a self-funded group transitions from one carrier or TPA to another, an independent firm—such as BMI, AIM, or Medbill—steps in to make sure everything is configured correctly. The goal is simple: catch potential issues before they impact your members or your bottom line.
This audit typically includes:
- Collecting and reviewing all plan documentation from the client and carrier/TPA.
- Validating the carrier/TPA’s implementation processes and system setup.
- Creating sample claims to test critical benefit rules like copays, out-of-pocket limits, exclusions, and limitations.
- Submitting test claims and analyzing results for accuracy.
- Reporting findings, including any discrepancies or risks that could lead to claim errors.
By taking these steps, the audit ensures that the new system aligns with plan documents and is ready for real-world claims processing.
Real-World Example
MB team—Jacob O., Lindsey N., Renee D., and Getta M.—recently partnered with a large self-funded client during their transition to a new carrier. Here’s what happened:
- We negotiated a $15,000 implementation credit with the new carrier.
- BMI performed the audit for $13,380, with the client’s time commitment totaling just 3 hours.
- The audit spanned 14 weeks, running from late Q4 2025 into early Q1 2026.
The result? A seamless implementation and peace of mind for the client.
Why It Matters
Fiduciary responsibility is under increasing scrutiny. The Department of Labor expects plan sponsors to act in participants’ best interest—and a pre-implementation audit is a clear way to demonstrate that commitment. It’s not just about compliance; it’s about protecting your organization and your members from unnecessary risk.
We encourage you to view this audit as an investment in confidence and trust. By taking this step, you’re not only avoiding potential errors—you’re building a stronger foundation for your health plan administration.