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    6 Replies Latest reply on Apr 29, 2009 4:15 PM by Mysabine

    Medical Claims Auditing

    gstevens25 Newbie
      I have been trying to find information on medical claims auditing. I have experience in processing medical claims and would like to start a business that audits medical claims to make sure they were not overpaid. I would like to specialize in medicare.

      I have been trying to get information on the correct type of software, but no luck.

      If anyone could help with any ideas on how to get started with this, or which auditing software would be helpful? I have tried my SCORE, but no one knows much about this type of businese.
        • Re: Medical Claims Auditing
          LUCKIEST Guide
          25, That is a great question. I am a SCORE Counselor and will research SCORE tomorrow
          and get back to you.
          There has to be info on medical claims auditing out there. Yes it a speciality but it must be available
          What is your background?? Did you go to college?? And what was your major??
          Have you tried Blue Cross??, Oxford insurance?? Hospitals
          Think outside the box, LUCKIEST
            • Re: Medical Claims Auditing
              gstevens25 Newbie
              My background is in processing medical claims for different insurance companies. I know how they work.

              I am in college, my last year for my degree in Accounting.

              There are companies out there, its just hard getting information on how to get started. I want to start this the right way.
            • Re: Medical Claims Auditing
              Lighthouse24 Ranger

              It sounds as though you want to be an independent medical claims auditor. In what state are you located? I'm asking because the first step would be to determine if and how your state managers or regulates that function (some do, some don't) -- and the next step would depend on the answer to that.
                • Re: Medical Claims Auditing
                  gstevens25 Newbie
                  I live in Ohio. I see information online about other companies that offer this services. I would like specialize in medicare claims, but would work with other insurance companies.


                  Basically, if I don't find any errors, I don't get paid. If I do find errors, I get paid a percentage.
                    • Re: Medical Claims Auditing
                      Lighthouse24 Ranger

                      One suggestion would be to start by contacting agencies like Accountemps, OfficeTeam, and Insurance Overload Staffing -- that seems to be where the companies you are referring to go when they need either temporary or permanent staff with your background. Even if you didn't want to work through them long term, it would get you started quickly and give you a chance to see how another audit operation is set up and managed -- all of which would give you knowledge and insight to launch your own independent firm eventually.
                      1 of 1 people found this helpful
                  • Re: Medical Claims Auditing
                    Mysabine Newbie
                    Hello gstevens -

                    You have expressed an interest in starting a business auditing medicare claims. By now you may have heard about the RAC Audits in which CMS has hired on a contingency fee basis 4 companies to perform audits of Medicare claims. In the trial audits done to see if this system should be put in place, CMS found millions of dollars in over-payments to physicians and hospitals. You can find out more information by going to the

                    If you are thinking about working from the physician side to help them by doing a risk analysis, I think you may be a little late in entering the arena. There are already several companies which do this sort of thing. Google "RAC Audits" and the search will yield all the companies who have software and want to do assessments for physicians and help them get their billing practices in order to minimize any future errors in filing claims.

                    With your knowledge and experience, it is possible you may be a good fit with one of those four contracted companies. This is probably not the answer you wanted to hear, but this should at least be part of your research before you commit to opening a business for which there may be no work.