Insurance Claims Review (Healthcare) Audit Work Program

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This sample healthcare audit program is intended to assist in determining whether internal controls in the health insurance claims review process are in place and working effectively. This audit program addresses topics such as duplicates, claim payment calculations, claim approvals, electronic Medicare claim files, reconciliation systems for claims processed, vendor data, claims filed, medical records investigation, random audits, claim committee and underwriting review, and refund status.

This document can be used as a general guide to understand and review these processes.

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