Accident & Health Auditing Services

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.

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.

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.

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.

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.

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.

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.