Medical Healthcare Claim Audits – Silence Is Not Golden

some of the time. For example, If you don’t know what you’re talking about, or just don’t have anything nice to say, silence is probably the best bet. If an argument is going nowhere or a conversation turns uncomfortable, not speaking is probably a wise strategy then, too. Even the greatest boxer of all-time, Muhammad Ali, is known for his thoughts on the subject. “Silence is golden when you can’t think of an answer.”

But, as with most things in life, there are exceptions. There are times when keeping quiet can actually hurt you. A first date? Not a good time for the silent treatment. See something wrong that needs to get righted? Please speak up.  And a date at the doctors? You know it’s time to come clean and chat. If you don’t, your doctor won’t know what to look for.  

In the world of medical claim audits, silence is most definitely not always golden. As a matter of fact, sometimes silence could indicate your profits might be falling into the red.

Here are some examples worth examining that clearly indicate ‘silence is golden’ does not apply when it comes to the administration of your self-funded plan.

  • If you receive very few complaints from employees or members, it’s probably not a good thing. This silence is likely an indicator that your third party administrator (TPA) is paying for everything, or more than what the policy plan allows whether you intend to or not.
  • If your self-funded plan does not address specific exclusions, there could be problems. For example, you might be under the impression that a certain condition isn’t covered, but you’re TPA might think otherwise. Why? Because it wasn’t included in the plan language. Before this happens to you, speak up!
  • If your administrator’s policies or systems aren’t in line with your written plan documentation, your TPA might be paying out when you don’t think they should be. For instance, your plan could specifically exclude weight loss surgery, but if your TPA’s medical team deems it medically necessary, they pay for it anyway. Sound like something you might want to speak up about? So do we.

A CTI medical claim audit can help you get to the bottom of all of these problems. Let us help you find the leaks so we can speak up and stop them together. To learn more about CTI’s industry-leading medical healthcare claim audits, please click here. For an in-depth look at our comprehensive medical healthcare audits and how they differ from other offerings, click on the graphic below. If you’d prefer to speak to one of our industry experts, you can contact us here.


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