Sampling Medical Insurance Claims for an Audit Challenge

Problem

A federal agency alleged that a state Blue Cross Blue Shield organization had benefited improperly from their dual role as an administrator of federal Medicaid insurance and a provider of private health insurance.

Procedure

Retained by this Blue Cross Blue Shield to determine the facts, Analysis & Inference designed exhaustive sampling and auditing of pertinent claims and member files in the insurer's massive databases.

Result

At the negotiations, Dr. William Fairley of Analysis & Inference assisted the insurer's counsel in explaining the sampling methodology. The provider satisfied federal investigators that breaches of their duties as administrator did not occur, or occurred in negligible degree and amount.