Most health plan audits stop at the claim. Employers and their third-party administrators pull paid claims, check eligibility against the payroll file, hunt for duplicate payments and overpayments, review pharmacy benefit manager contracts for spread pricing, and confirm that plan documents and summary plan descriptions are current. Those checks catch money that already left the plan. They miss the more expensive question: what did the plan do before the claim?
US healthcare spending runs about $12,900 per person per year. Premiums climb 5 to 7 percent a year. Yet only 32 percent of adults get an annual physical, and roughly 8 percent complete all recommended preventive care. A plan can pay every claim accurately and still fail on cost, access, and prevention.
The missing line item is avoidable utilization: emergency visits for untreated chronic conditions, late-stage diagnoses, care that costs more because earlier and cheaper options were skipped.
The Post-Claim Checklist Most Plans Run
A standard audit checks:
- Eligibility against the payroll file, including dependent verification.
- Duplicate payments, overpayments, and coordination of benefits.
- PBM contract terms, spread pricing, rebate pass-through, and drug list changes.
- Stop-loss thresholds, large claim triggers, and laser claims.
- SPD and plan document match to current plan design.
- ERISA, HIPAA, COBRA, and Section 125 documentation.
- Form 5500 filings and nondiscrimination testing.
That list catches money that already left the plan.
Eight Pre-Claim Questions Most Audits Skip
These go before the claim. Each one names a data source and a warning sign.
- Prevention completion rate. Ask the claims administrator or TPA for the percentage of covered adults with a preventive visit in the last 12 months and the percentage who completed age- and risk-appropriate screenings. Compare that to baselines of about 32 percent for annual physicals and roughly 8 percent for full recommended preventive care. Warning sign: a plan that waives preventive cost sharing but still lands below those baselines.
- Entry point analysis. Pull 12 months of claims and sort by place of service: emergency department, urgent care, primary care, telehealth. Count episodes per place and average paid per episode. Warning sign: high volume of ER or urgent care visits for conditions a $0-copay primary or telehealth visit could have handled.
- First-dollar benefit gap. Review the summary of benefits and coverage. Find what a member pays for primary care, telehealth, urgent care, and common prescriptions before the deductible. Warning sign: no $0-copay primary care or telehealth option. When a strep test carries a deductible, members wait. Some get sicker.
- FSA and HSA midyear depletion. Ask the benefits administrator for the percentage of participants who exhaust their FSA or HSA by June or July. Warning sign: high early depletion means the plan pushes routine costs onto employees before they have saved enough. It also predicts skipped care later in the year.
- Chronic condition visit gap. Use claims data to identify members with diabetes, hypertension, or asthma. Cross-reference against primary care visits in the last 12 months. Warning sign: diagnosed members with no visit. That absence is a future inpatient admission waiting to be scheduled.
- Employee comprehension test. Survey a sample of employees on three questions: what the plan covers, where to go first for care, and what a preventive visit costs. Warning sign: employees cannot answer those three questions.
- Preventive action verification. Confirm whether the plan has a mechanism to verify that preventive actions actually happened, not just a code for a visit. Warning sign: a participation-only incentive that rewards surveys or video watching. That measures attendance, not health.
- Renewal-input linkage. Ask your broker whether audit results feed next year's plan design. Warning sign: the audit ends with a report and no design changes.
This list catches money that has not left yet.
Why the Two Checklists Work Together
A post-claim audit catches money that left the plan. A pre-claim audit catches money that will leave the plan in the next 12 to 24 months. About 1 in 3 Americans skip care or prescriptions because of cost. That decision is not random. It follows benefit design.
Members make cost decisions before the claim exists. Their choices determine which claims an audit later reviews. A plan that charges a deductible for primary care shows fewer primary care visits, accurate claim payments on those visits, and a higher volume of urgent care and emergency department claims in the following quarter. That is accurate billing. It is also higher future spending.
Where a WellthCare Plan Fits on This Checklist
Some pre-claim checks are hard to run because a traditional plan records prevention only when it becomes a paid claim. A WellthCare Plan changes the record. WellthCare™ is the first Health-to-Wealth™ Benefit System. It works alongside an employer's existing ACA-compliant group health plan and gets used first.
Members receive $0-copay care for defined services that may include preventive evaluations, telehealth, urgent care, diagnostics, chronic condition management, and pharmacy services. The platform verifies preventive actions through standardized preventive care codes. Each verified action earns reward dollars at the WellthCare Store™ and builds automatic retirement contributions funded by savings the employer commits.
Employers get a record that shows prevention happened, not just that a visit was billed. The WellthCare Readiness Index™ converts 6 to 12 months of real usage into a projection of when and how much savings would come from expansion. The audit becomes a planning document, not a once-a-year invoice review.
Start with the pre-claim questions. Give the list to your broker or TPA and ask for the data. Then ask what a WellthCare Plan would look like for your team.
This article is for general information only and is not legal, tax, or medical advice. Employers should consult their own advisors.