SCD has performed numerous claims audits for its clients. These claims audits have been of workers' compensation, casualty / liability, property, or collegiate athlete medical insurance programs.

We compare the quality of claims management performance against one or more documented procedures:

  • Leading industry practices, which are activities that insurers, TPAs, and self-administered programs have developed that assist the adjusters and supervisors in working toward optimal outcomes.
  • Contractual requirements, either in the form of the formal contract or in the form of special service instructions that have been developed that clarify roles and responsibilities of the client and the claims administrator.
Audit checklist

Claims audits provide valuation information to improve the level of service and ensure that the claims administrators know that their activities are being fairly and objectively measured.

We will also review loss and management reports, procedures manuals, and other documents. These will provide us with additional background information regarding your program.

We will randomly select a sample of claims for the claims audit. The sample will include claims from each line of business, claim office, or adjuster to meet your needs.

We have developed a claims audit template that allows us to evaluate how a claims administrator's activities compare to these metrics. We review the claim files to assess the performance compared to these activity-based requirements. We also review the outcomes of the claims management work based on the action plans developed by the claims personnel.

Based on our evaluation, we provide our clients with a draft report which measures the claims administrator's performance in several critical claims management areas, and identifies any gaps between its performance and the standards. We then provide recommendations to close any gaps. We assist our clients in setting priorities for improvement.