Medical Aid Claims Audit Program — v1.0

Claims are where the money flows — and where the risk is highest. This Medical Aid Claims Audit Program gives auditors, forensic investigators, and compliance teams a structured, data-driven framework to audit health insurance and medical aid claims from every angle. With 71 audit procedures across 9 specialist sections, it covers everything from proving posting totals to detecting ghost providers, duplicate claims, and fraud patterns that standard reviews miss entirely. Each procedure comes with detailed audit steps and the exact data source required — so you can move from planning to fieldwork without reinventing the wheel. Whether you are auditing a medical scheme, a health insurer, or a third-party administrator, this program tells you exactly what to test, how to test it, and what evidence to collect.

Product Summary — Sections at a Glance

Section 1 — Calculations and Posting Totals (6 procedures)
The foundation of any claims audit. Proves that all claims posted reconcile to the general ledger, that batch totals are correct, that claim reference sequences are complete, and that period cutoff is accurate. Also covers re-insurance threshold testing.

Section 2 — Claims Analysis (8 procedures)
Statistical deep-dive into the claims portfolio. Analyses claims by month, claim type, product, benefit code, provider, and geography. Calculates average claim values and approval rates by assessor to surface anomalies in the data.

Section 3 — IBNR Analysis (6 procedures)
Assesses the adequacy of incurred-but-not-reported reserves by building incident-to-report date matrices, calculating average reporting lags by claim type, and identifying late-reported claims. Includes claims development triangle analysis and post-period-end claims review.

Section 4 — Exception Tests (8 procedures)
Targets individual claims outside expected parameters — high value outliers, dormant claims with no movement in 6 months, negative balance recoveries, round-amount claims, and claims processed outside business hours. Includes Benford’s Law analysis and override approval testing.

Section 5 — Duplicates and Gaps (8 procedures)
Detects exact and partial duplicate claims by matching on policy number, claim amount, and date of incident. Identifies sequence gaps in claim reference numbers, duplicate provider invoices, and duplicate payments. Exposes members and providers making a business out of repeat claiming.

Section 6 — Policy Cross-Matching (8 procedures)
Cross-matches every claim against the policy master file — testing policy existence, policy active status at date of claim, beneficiary membership, benefit entitlement, and waiting period compliance. Includes the early inception test to identify claims submitted within 30 to 60 days of policy start.

Section 7 — Provider and Beneficiary Tests (8 procedures)
Validates the existence and legitimacy of healthcare providers and beneficiaries. Tests for ghost providers by matching provider banking details to employee and member accounts. Identifies deceased member claims, ghost beneficiaries, and providers billing outside their registered speciality.

Section 8 — Fraud Indicators (10 procedures)
Structured red flag analysis covering threshold avoidance, rapid succession claims, consistent provider billing amounts, missing documentation, employee claims patterns, assessor self-approval, new provider high-volume surges, and claim refund-and-resubmission patterns.

Section 9 — Process and Controls (10 procedures)
Assesses the end-to-end claims processing control framework — segregation of duties, delegation of authority, pre-authorisation compliance, turnaround time compliance, system access controls, recovery and subrogation processes, third-party administrator oversight, and regulatory compliance.

Plus: Consolidated Findings Log and auto-scoring Compliance Dashboard.