Title: Health Plan Claims and Billing Audits
Source: https://ethosbenefits.com/services/audits
Publisher: Ethos Benefits
Summary: Ethos Benefits audits your health plan invoices and eligibility, coordinates claims audits with your vendors, and tracks every recovery to completion.

1.  [Home](https://ethosbenefits.com/)
2.  [Services](https://ethosbenefits.com/services)
3.  Claims, billing and eligibility audits.

# Claims, billing and eligibility audits. Stop paying for what you don’t owe.

Your plan pays invoices and claims every month, and errors add up quietly: coverage billed for people who left, dependents who are no longer eligible, claims paid outside the contract. Ethos Benefits audits billing against your records, reviews eligibility, coordinates claims audits with your vendors and tracks each recovery to completion.

[Request a Strategic Analysis](https://ethosbenefits.com/strategic-analysis)

## What you get.

Most invoices are paid as billed. Without a monthly check against your own records, overpayments can run for months before anyone notices.

1.  **Billing reconciliation** Carrier and vendor invoices checked against your HR records and carrier enrollment, with each discrepancy listed and followed up.
2.  **Eligibility and dependent audits** Enrollment checked against plan eligibility rules, including dependent eligibility, with a plan to correct what doesn’t match.
3.  **Claims audit coordination** Claims audits arranged with your administrator or PBM under the audit rights in your contracts, with the findings reported to your committee.
4.  **Stop-loss reimbursement audit** Every eligible large claim checked for submission and payment under the stop-loss policy.
5.  **Fiduciary practices audit** Your plan documents, committee record and vendor oversight reviewed against ERISA’s requirements, with the gaps prioritized.
6.  **Recovery tracking** Every overpayment and recovery tracked until it is resolved, and reported in your record.

## What gets _audited._

| Audit | What it checks | How often |
| --- | --- | --- |
| **Billing reconciliation** | Invoices against HR and carrier records | Monthly |
| **Eligibility** | Enrollment against plan rules, including dependents | Annually or at implementation |
| **Claims** | Claims paid against plan terms and contract pricing | Under your contract’s audit rights |
| **Stop-loss** | Reimbursements filed and paid | Throughout the policy year |
| **Fiduciary practices** | Documents, committee record and vendor oversight | Annually |

## Your _right to audit._

An audit is only possible if the contract allows it. That is why audit rights are written into every contract during [procurement](https://ethosbenefits.com/services/procurement), and why results are measured under [vendor management](https://ethosbenefits.com/services/vendor-management).

## Part of your Fiduciary Framework™.

Every Ethos service reports to your benefits committee. The work is reviewed at your quarterly committee meeting, each decision is recorded with the reasoning behind it, and the record lives in your Ethos Fiduciary OS. That is what lets your committee show the plan was run prudently.

[See the Fiduciary Framework™](https://ethosbenefits.com/fiduciary-framework) · [How fiduciary governance works](https://ethosbenefits.com/services/fiduciary-governance)

## Related reading.

-   [**The employee benefit plan audit** Benefits 101: Which employee benefit plans need an independent audit with Form 5500, why most insured and self-funded health plans are exempt, and what the audit covers.](https://ethosbenefits.com/benefits-101/employee-benefit-plan-audit)
-   [**Common invoice issues and evidence of insurability** Insight: How evidence of insurability (EOI) for life and disability coverage causes invoice errors and denied claims, and how employers can audit and fix the process.](https://ethosbenefits.com/insights/evidence-of-insurability-invoice-issues)
-   [**What happens behind the scenes with your health insurance?** Insight: Where an employer's health plan premium dollar goes, where costs hide in networks, PBMs and claims, and the plan data federal law says you can get.](https://ethosbenefits.com/insights/what-happens-behind-the-scenes-with-your-health-insurance)

[Browse everything in Learn](https://ethosbenefits.com/learn)

## Questions employers ask about this.

How often should invoices be audited?

Every month. Billing errors repeat until they are caught, so a monthly reconciliation catches them before they compound.

Can we audit our administrator or PBM?

If your contract allows it. Audit rights, including how often, with whose auditor and at whose cost, are negotiated during procurement so your plan can use them.

What is a dependent eligibility audit?

A review that confirms each covered dependent meets the plan’s eligibility rules, usually by asking employees for documentation. Removing ineligible dependents reduces claims the plan should not be paying.

## Keep reading Related to this page.

-   [**Claims analytics** Your company owns its health plan data. Ethos Benefits connects your claims and pharmacy data to analytics and reviews it with you every month. _Read more_](https://ethosbenefits.com/services/claims-analytics)
-   [**Vendor management** Ethos Benefits holds your health plan vendors to their contracts with service level agreements, performance guarantees, KPI scorecards and quarterly reviews. _Read more_](https://ethosbenefits.com/services/vendor-management)
-   [**Stop-loss procurement** Ethos Benefits markets, places and renews stop-loss coverage for self-funded health plans, and audits the contract so the policy pays when it should. _Read more_](https://ethosbenefits.com/services/stop-loss)
-   [**Benchmarking and modeling** Ethos Benefits benchmarks your plan design and contributions against similar employers and models the cost and affordability of every change before you make it. _Read more_](https://ethosbenefits.com/services/benchmarking)
-   [**Underwriting and rate analysis** Ethos Benefits checks the underwriting behind your renewal, projects claims from your data, and builds premium equivalent rates for self-funded plans. _Read more_](https://ethosbenefits.com/services/underwriting)

## See what your plan is really costing you.

A Strategic Analysis starts with your plan documents and your broker agreement, then shows you what your plan costs, where the risk sits, and what a committee would decide with the full picture.

[Request a Strategic Analysis](https://ethosbenefits.com/strategic-analysis) [Call (407) 803-4710](tel:+14078034710)