Accident & Health Auditing Services

Leveraging extensive industry knowledge and expertise to deliver quality and comprehensive audits.

Accident and Health Digital Brochure

Audits customized to meet your objectives

Davies specializes in accident and health audits to risk-bearing entities, such as employer group’s self-funded health plans, third-party administrators (TPAs), managed care organizations, MGUs, carriers, and reinsurers. Davies is known for delivering exceptional quality, extensive industry insight and knowledge, focused and precise risk assessment, and detailed audit reporting.

Our services are designed to strengthen the entity being audited and the risk relationship between the audit subject and the risk-bearer. Each audit is performed by tenured auditors who have an average of 35 years of experience in the industry. We begin audits with an individualized audit plan customized to meet your specific auditing objectives and preferences to meet your organizational goals.

Davies’ accident and health specialists work as an extension of your team. We see ourselves as strategic partners for your organization and center our services around technical and operational expertise.

Accident & Health Audit Insurance Services

We serve our clients with a variety of accident & health audits, including:

TPA Audits

Our team can formulate the scope of the audit to meet any due diligence concerns and requirements. These audits are highly customizable and may include claim operational audit, stratified statistically valid random sample claim audit, random sample claim audit, focused top-100 claims paid audit, and targeted issues audits.

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Aggregate Audits

We provide aggregate audit services, commissioned by MGUs, carriers, and reinsurers. To date, we have audited nearly $200 million in aggregate claims with an average savings of almost 30% for this type of loss exposure. To deliver these savings, we audit calculations submitted by TPAs and apply Plan Document and Stop Loss contract terms and provisions to all elements of the claim. Clients receive thorough reporting, reimbursement recommendations, and findings.

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Carrier and Reinsurer Audits

Davies confirms the business mix underwritten to the reinsurers and that the business complies with the intent of the parties to the reinsurance agreement(s). Our specialists can perform underwriting, claims, and premium administrations audit components as part of carrier and reinsurer audits.

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MGU Audits

To address the needs of MGU audits commissioned by carriers and reinsurers, we review and evaluate all phases of the specific MGU’s operations. These phases include underwriting administration, premium administration, claim administration, TPA oversight, data protection, and disaster recovery. At the conclusion of the audit, we meet with the MGU to discuss findings, industry standards, and best practices to strengthen the organization’s overall administration.

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Premium Audits

These comprehensive audits are available for risk-bearing entities that want to understand the designated audit subject’s premium administration. These audits also include a technical audit component to ensure quality and adherence to the audit subject’s internal policies and procedures as well as industry-standard practices. Premium audits also include verification that the premiums paid accurately reflect any census changes that occurred during the contract year.

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Specific Claim Audits

Davies’ Specific Excess Claims audits include an extensive review of claims paid to ensure they adhere to the underlying Plan Document as well as the stop loss contract. Our auditors conduct verifications, which consist of all aspects of eligibility and disclosure with observations of cost mitigation efforts. We provide detailed reporting and outline findings uncovered along with recommendations for improvements.

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Litigation Support

In the event of litigation between a carrier/reinsurer and the policyholder, our auditors can serve as experts, retained by the carrier’s/reinsurer’s legal counsel.

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Due Diligence, Careful Analysis, and Niche Expertise

When you need a strategic partner that understands your business objectives, potential implications of risk, and the accident and health landscape, turn to Davies. We have the experience and expertise to manage even the most niche of claims management needs. Our accident and health audit and claims management solutions are backed by due diligence, careful analysis, and a commitment to exceptional customer service.

Accident & Health Auditor

Key Contact

Dave Valenzano

President Actuarial, Audit, and Consulting

Susan Arsenault

Senior Vice President

Timothy Bracco

Vice President- Operations