Benefits Audit Services
Nobody Told Me That™ · Services
The Enrollment & Invoice Reconciliation Audit
Your ben admin system, your carriers, and your invoices should all tell the same story. Every quarter, I prove whether they do.
The whole job in one sentence. I check whether the people your carriers are billing you for are the same people your system says are covered. They almost never are. Every month that gap sits there, it costs you money.
Right now you probably have an employee who left in March and is still covered at the carrier. A dependent who turned 26 last year and never came off. Somebody whose coverage says employee plus spouse in your system and family on the bill. You are paying for all three, and nothing in a normal benefits process is built to tell you.
In plain terms, this is three steps
1. I compare your three lists. Who your system says is covered. Who the carrier says is covered. Who you are actually paying for.
2. I put a dollar figure on every difference. Not a flag in a report. The real amount, and how far back it goes.
3. I get the money back, then I tell you why it happened. The credit requests, and the reason behind them, so the same mistake stops repeating.
No charge for the first call and no pitch deck. Send one line about your situation and I will come back with a few times. You tell me how your enrollment data moves, I tell you where a setup like that breaks.
Who this is built for
Employers who pay carrier invoices without the ability to check them
This is for the person who signs off on the benefits invoice every month and quietly hopes it is right. HR directors, benefits managers, controllers, and CFOs at employers running roughly 100 to 2,500 enrolled employees, fully insured or self funded.
It is a particularly good fit if any of these are true:
- You send a file to at least one carrier telling them who is covered (the EDI 834, the carrier file feed) and nobody opens the error reports that come back.
- You changed ben admin systems, carriers, or payroll providers in the last 18 months.
- You went through an acquisition and inherited an enrollment population you did not build.
- Your benefits invoice gets approved on volume and headcount, not line by line.
- You are self funded, which means a bad eligibility record is not a billing problem, it is a claims problem.
- Your team is good at benefits and nobody has 40 uninterrupted hours to reconcile 12 months of invoices.
Who this is not for. If you want someone to pick your carriers, run your renewal, or replace your broker, that is not this. I do not sell insurance, I do not take commissions, and I do not have a quota. I check whether what you already bought matches what you are already paying for.
The problem, stated plainly
Three systems are supposed to agree. Nobody is assigned to check.
When all three agree, nobody notices and nothing needs doing. When two of them agree, you are still paying for the one that is wrong.
Your invoice cannot catch this. The invoice gets built from the carrier’s own list of who is covered, so it will always agree with the carrier. It is a bill, and no amount of reviewing a bill will tell you the list behind it was wrong to begin with.
What usually turns up
This is not a list of theoretical risks. This is what the match actually finds.
- Terminated employees still active at the carrier. Sometimes for a month. Sometimes since last plan year.
- Dependents who aged out at 26 and were never removed, because the age-out report goes to an inbox nobody owns.
- Tier mismatches. They elected employee plus spouse, the carrier has them at family, and you have been paying the difference every month since.
- New hires who elected, got deducted, and never reached the carrier at all. Those surface as a denied claim and an angry employee, usually at the worst possible moment.
- Employees on unpaid leave with no premium coming in, no arrears balance tracked, and no plan for collecting it when they come back.
- COBRA participants billed at active rates, and active employees sitting on the COBRA roster.
- Life insurance above the amount an employee can get without answering health questions, where the employee never filled out the questionnaire. You pay the premium every month. The carrier declines the claim when the family files it. The employee dies believing they were covered, and the premium matching the coverage amount is exactly what hides this one.
- Life and disability coverage still based on a salary from two raises ago, so the coverage amount is too low and the premium is wrong in whichever direction nobody checked.
- Carrier file errors that have been failing quietly since a mid-year plan change, dropping a few people every time the file runs.
- Retro adds and retro terms sitting outside the carrier’s credit window, which is the part that actually costs you money. More on that next.
Cadence
Why quarterly, and why annual is too late
Most employers who do this at all do it once a year, usually right after open enrollment. That is better than never, and it still leaves most of the money on the table. Money is also not the only thing on a clock here. Some of these windows close on your employees.
Carrier credit windows close
Most carrier contracts limit retroactive credits to something like 60 or 90 days. Find a termination three months late and you get the premium back. Find the same termination eleven months late and the money is simply gone. You donated it. Quarterly exists so that discoveries land inside the window instead of outside it.
Payroll arrears become uncollectible
A missed deduction found in the same quarter is a conversation and a catch-up schedule. The same miss found a year later is a four-figure balance you are either writing off or asking a current employee to repay out of one check. Neither of those is a good day.
Your renewal is priced off your enrollment
Carriers and underwriters quote from the census and the claims you give them. If your enrollment data carries phantom lives and wrong tiers all year, your renewal and your budget are both built on numbers you cannot defend in the room where the decision gets made.
ACA reporting is built all year, not in January
Offer and coverage codes on the 1095-C come from the same eligibility records being audited here. Cleaning them quarterly means January is a reporting exercise instead of a four-week archaeology project with a filing deadline attached.
If you are self funded, read this part twice
A bad eligibility record is not a billing error. It is a claim.
If you are self funded, you pay your employees’ claims out of your own money, and you buy stop loss insurance to cover you when one person’s claims get very large. That insurance starts paying at a set dollar point. Everything under that point is yours.
Here is why a clerical error matters so much more in that setup. On a fully insured plan, a record that should have been shut off costs you premium. Annoying, usually recoverable. On a self funded plan it costs you the claim itself, and the trip from small mistake to large number is shorter than people expect.
- Someone leaves. The termination never reaches the company paying your claims, so their coverage stays switched on.
- They keep using the card. Maybe for months. Those claims come out of your money, because as far as anyone processing them can see, this person is covered.
- One of those claims is big. It goes past the point where your stop loss insurance is supposed to take over, so you file to get reimbursed.
- Then the stop loss carrier does the one thing nobody plans for. They check whether that person was actually eligible on the day they got the care.
- They were not. The reimbursement is denied.
Your plan just absorbed a claim it never owed, and your next renewal gets priced on it.
That is the whole scenario. It is not rare and it is not complicated. All it needs is for nobody to have compared two lists, which is exactly the comparison no routine process in a normal benefits department performs.
So for self funded plans I check three lists instead of two: your own system, the list held by whoever processes your claims, and the list your stop loss carrier thinks they are covering. Getting those three to agree is the cheapest protection in your entire benefits budget. It costs a fraction of one denied claim.
Scope
What actually gets audited
Every line of coverage you offer, not just medical. Here is the full checklist I work from.
Enrollment match
- Census from the ben admin system against carrier eligibility, person by person
- Every line: medical, Rx, dental, vision, basic and voluntary life, AD&D, STD, LTD, EAP, accident, critical illness, hospital indemnity
- Coverage tier on each line
- Effective dates and termination dates
- Dependents, with age-out and student status checks
- Plan and network code accuracy
- Error reports that came back from the carrier file feed, for the whole period
- Records that exist in one system and not the other, in both directions
Invoice reconciliation
- Carrier invoices line by line against audited enrollment
- The three-way match: what they chose, what payroll took out, what the carrier charged
- Rate accuracy against the signed rate sheet, including mid-year changes
- Salary-based volume checks for life, STD and LTD
- Retro adds and retro terms, with each one dated against the carrier credit window
- Proration and partial-month handling
- Credits a carrier already promised you and never actually applied
- Where you tell the carrier what to charge, whether what you told them was right
- Employee and employer cost split, so your GL is funding the right share
Risk and eligibility
- Life insurance above the automatic amount where the health questionnaire was never completed
- What your plan document says about who is eligible, against how the system was actually set up
- Waiting periods and new hire windows applied the way the plan says
- Anyone on leave: FMLA, short and long term disability, military, personal
- COBRA list against the active list, in both directions
- Rehires, and whether their prior service was counted correctly
- Part time, variable hour, and seasonal eligibility determinations
- Retirees and anyone on a legacy arrangement nobody remembers approving
- Self funded: the list held by whoever pays your claims, against the list your stop loss carrier has
Deliverables
What you actually walk away with
Findings you can hand to a carrier, a CFO, or an auditor without rewriting anything first.
1. The discrepancy register
Every mismatch, one row each. Employee, line of coverage, what your system says, what the carrier says, the dollar variance, how far back it goes, severity, the recommended action, and who owns it. This is the working document, and it is yours to keep.
2. The invoice reconciliation workbook
Each month of the audited period reconciled line by line, with variance totaled by carrier and by line of coverage, and a clean tie-out to what you actually paid.
3. The credit recovery tracker
Every credit worth requesting, with the amount, the carrier contact, the date requested, the credit window deadline, and status. I write the requests and work them to resolution, not just to submission.
4. The root cause memo
The part that matters most for next quarter. Most discrepancy volume traces back to a handful of upstream problems: a mapping error in the feed, a termination process that depends on one manager remembering, an eligibility rule configured the way somebody assumed it worked. I name them and tell you how to close them.
5. The one page executive summary
Dollars identified, dollars recovered, exposure avoided, and the three things that need a decision. Written so you can forward it to your CFO without translating it first.
6. The debrief call
Ninety minutes on the findings with you and whoever else needs to be there. I answer every question, including the ones about things we found that are nobody’s fault and still have to get fixed.
Process
How a quarter runs
Three to four weeks from data in hand to debrief, and most of that time is mine, not yours. Your team’s real commitment is the data pull up front and roughly two hours of exception review in the middle.
Your lift
What I need from you
You get this list in writing on day one. I am putting it here so you can see the commitment before you book anything, and so you know whether you can even produce it. If you cannot, that is itself a finding worth knowing about.
Data
- Enrollment extract from the ben admin system as of the audit date
- Carrier eligibility or bill-level detail files for each carrier
- Carrier invoices for the period, Excel or CSV if possible
- Payroll deduction register by employee by pay period
- Termination and new hire reports for the period
- COBRA roster and leave of absence roster
- Error reports that came back from your carrier file feed
- Self funded: the eligibility file from whoever pays your claims, plus your stop loss contract
Documents and access
- Signed rate sheets for every line, including mid-year revisions
- Plan documents or SPDs with the eligibility language
- Your benefits administration calendar, if one exists
- A named internal contact who can answer questions in under 48 hours
- A letter of authorization naming me to each carrier
- Roughly two hours of that person’s time for exception review
One honest note on data. I would rather have a messy file than a cleaned one. If somebody tidies the extract before sending it, the errors I am looking for are the first thing to disappear. Send it raw.
Why this is not the same as hiring an audit firm
An auditor finds the number. Someone who has run benefits finds out why.
I get calls from audit companies that want to do this work. They are genuinely good at auditing. Most of them have never administered a benefit plan a single day in their lives.
I am the other thing. I learned this by doing the job, not by reading a methodology. I do not work in hypotheticals and I am not guessing at what works, because I spent twenty years as the person whose name was on it when it broke.
That is not a small gap. It is the entire job. Finding out that two numbers do not match is the easy half. The reason they do not match lives in your plan document, your eligibility rules, your deduction setup, your stop loss contract, and your dependent rules. If you have never had to run those things, you do not know where the holes are. You will find the difference, write it down, and walk straight past the thing that caused it.
Numbers matter. But a number with no cause attached is a number you get to find again next quarter.
Six findings, all of them off my own desk. Here is each one handled both ways. The first is the one I would want you to read even if you skip the rest.
There is a person on the invoice who is not on the enrollment census
Catches it, and correctly. Your system has her terminated, the carrier has her active, and you are paying a premium for her every month. They report the overpayment and a recovery figure. Engagement complete.
They are right, and the number is right, and the premium is the least important thing in this finding.
I worked this one. Here is what that variance actually was. An employee old enough for Medicare dropped the company plan at open enrollment so Medicare would be her primary coverage. The drop never took at the carrier, and the reason is the kind of thing you only know if you have built these files. Her election went out as a blank, and that carrier would not terminate anyone on a blank. They required an actual termination date. So nothing errored loudly, nothing landed on a report, and her coverage simply stayed on.
The carrier kept showing active employer coverage. That record flowed into Medicare’s files, and Medicare began denying her claims, because when an employer plan is active it pays first. She was suddenly facing the company plan’s deductible and coinsurance on care she had already received, which was far more than Medicare would have cost her. She was preparing a complaint to the Department of Labor. That is the correct place to take it, and she was not wrong to go there.
Terminating her at the carrier is half the fix. Somebody also has to get Medicare’s record corrected, which only one office can do, and Medicare’s automatic reprocessing of the denied claims reaches back about 180 days from the date that correction is applied. Past that line, she or her doctors have to chase every claim by hand.
An audit firm hands you a premium recovery number. The premium was never the problem.
A dependent turned 26 and is still on the plan
Flags an ineligible dependent. Recommends removal and calculates the overpayment.
Read the plan document before anybody gets removed, because 26 is the floor the law sets, not the date your plan actually drops them. Some plans end it on the birthday, some at the end of the birthday month, some at the end of the plan year. If you are a large employer there is a separate rule that says you have to offer it through the last day of the month they turn 26. That spread is weeks of premium in one direction or the other, and the system and the carrier are frequently set up differently from each other.
Then I check the two things that genuinely run past 26. A child who cannot support themselves because of a disability that started before they aged out. And the self-paid continuations a few states require on fully insured plans, where New Jersey runs to 31. That second one carries its own finding, because the dependent is supposed to be paying 102 percent of the premium and the employer is supposed to be paying none of it. If nobody set that up, you are quietly funding coverage somebody else owes.
Payroll deducted $212. The carrier billed $186.
Reports a $26 variance on that employee.
Ask which of the two is correct, which means pulling the signed rate sheet and the employee’s actual election. Then check the other 40 people on that same plan, because a wrong rate is almost never wrong for one person. One finding becomes forty, and the fix is one cell in a rate table.
An employee who left in March is still covered
Reports the overpayment and the recoverable amount. Engagement complete.
Recover it, then find out that terminations only reach the carrier when a manager remembers to complete a form. That is why there are four more coming next quarter. The recovery is worth money once. Knowing that is worth money every quarter after.
An employee has $300,000 in life insurance and the premium matches
Confirms the premium matches the coverage amount. No variance. Clean.
Check whether that person ever completed the health questionnaire required for the amount above what the plan gives automatically. If they did not, you are paying every month for coverage the carrier will decline when the family files the claim. This one never shows up as a variance. The premium matching is precisely what hides it.
An employee on leave has no deduction coming in
Flags a missing deduction against an active enrollment.
Ask three questions that decide whether it is even a finding. Is the leave paid or unpaid. Does your policy waive the premium or let it build up as a balance owed. And is anyone tracking that balance so it can be collected when they come back. At least one of those three answers is usually missing, and that is the real finding.
None of that is clever. It is just what you know after twenty years of being the person responsible when it goes wrong.
Investment
Flat fees, published, no contingency
Priced on enrolled employee count and number of carrier lines. You get a firm number before any work starts, and it does not move unless the scope does.
The Baseline Audit
$5,500
one time, up to 150 enrolled
The first one is the heavy lift. Full enrollment match on every line, 12 months of invoices reconciled, root cause analysis, and credits pursued as far back as your carrier contracts allow.
Required before quarterly service. You cannot monitor drift from a starting point nobody ever established.
Quarterly Reconciliation
$1,950
per quarter, up to 150 enrolled
After the baseline, each quarter is a delta review. New hires, terms, life events, tier changes, and three months of invoices. Credits get caught inside the window instead of after it.
Prepay four quarters and take 10 percent off. Month to month on a quarterly cadence otherwise, cancel with 30 days notice.
Project Work
$2,400
per day, two day minimum
System migration, carrier change, post-acquisition population cleanup, a specific mess somebody needs unwound, or a one-time deep dive on a single line of coverage.
Scoped to a fixed quote wherever the work can be defined in advance, which is most of the time.
How pricing scales
| Enrolled employees | Baseline audit | Each quarter after |
|---|---|---|
| Up to 150 | $5,500 | $1,950 |
| 151 to 500 | $8,500 | $2,950 |
| 501 to 1,000 | $13,500 | $4,250 |
| 1,001 to 2,500 | $19,500 | $6,500 |
| Over 2,500 | Quoted | Quoted |
Add $750 per quarter for each carrier beyond six. Multi-state or multi-EIN groups are quoted after the fit call.
Add-ons
| Add-on | Fee | When it is worth it |
|---|---|---|
| Stop loss eligibility cross-check | $2,200 | Self funded plans. Compares TPA eligibility to the stop loss covered population. |
| Dependent eligibility review, sample | $1,500 | A 50-record sample to size the problem before committing to a full verification. |
| Full dependent verification | $28 per dependent | Document collection and review across the whole population. |
| Life and disability EOI audit | $1,500 | Coverage above guaranteed issue with no approved EOI on file. |
| Extended credit recovery | $300 per hour | Only if a carrier is still stalling past the included 30 day follow up. |
The three ways you can buy this work
I am not going to publish someone else’s prices, because I do not know what they quoted you. What I can show you is how each one charges, because that part decides what you actually get.
| Contingency recovery firm | Traditional audit firm | This | |
|---|---|---|---|
| How you pay | A share of whatever they recover | Project fee, quoted per job | Flat fee, published above |
| Their background | Data and recovery | Audit and accounting | Twenty years running benefit plans |
| What they go after | The biggest recoverable lines | Whatever the contract scoped | Every difference, then the cause |
| Reads your plan document | No | Sometimes | Always, first |
| Root cause in writing | Not included | Sometimes, as a side note | Every quarter |
| Built to repeat | One time | One time | Quarterly |
| What makes their fee go up | Finding more | Billing more hours | Nothing. Fewer findings next quarter is the goal. |
That last row is the one I would read twice if I were buying. A contingency firm gets paid more when your plan is in worse shape. I get paid the same either way, which means I have no reason to leave the cause of the problem in place.
Why contingency costs more than it looks. Say a firm offers to work for 30 percent of what they recover, and they turn up $60,000. You pay them $18,000. Meanwhile the termination process that created the $60,000 is still exactly as broken as it was, so next year it produces another $60,000 and another $18,000 fee. That is not a recovery service. That is a subscription to your own problem.
The flat fee above is a fraction of that, and the part that makes next year smaller is the part no contingency arrangement will ever pay anyone to write.
Terms. Fifty percent to start, fifty percent at the debrief. Quarterly engagements bill at the start of each quarter. Invoiced through Stripe, net 15.
On return: I will not promise you a recovery number, because I do not know your data yet and anybody who quotes you one before looking is guessing. What I will tell you is that one terminated employee left active on a mid-size medical plan for two quarters generally costs more than the quarterly fee, and on a self funded plan a single denied specific stop loss reimbursement costs more than several years of it.
Who you are working with
Erica Kirby
Twenty years in employee benefits, nearly all of it on the employer side rather than the brokerage side. I have built the carrier files, run the open enrollments, sat on hold with the eligibility department, and written the credit request that finally got answered on the fourth try. I know what a ben admin system does when nobody is watching it, because I was the person responsible when it did it.
I earned this the slow way, and that is the part I would want you to weigh. Twenty years of being the person whose name was on it when a file failed, an invoice was wrong, or an employee called because a claim got denied and nobody could tell her why. You cannot get that education from a methodology. It is why I can tell you what a system does under pressure instead of what the manual says it does, and it is why I do not deal in hypotheticals. I know what works because I have had to make it work.
I am also the author of the Nobody Told Me That field guides, including the 90-Day Playbook for new benefits administrators and the Post-Open-Enrollment Audit framework, and I publish free plain-English benefits guides at ericakirby.com for the people running these operations every day.
I built this service because of a pattern I kept seeing from the inside. The things that cost employers the most money in benefits are almost never the things anyone is actively looking at. Nobody is assigned to compare the three systems. The invoice gets approved because it looks like last month’s invoice. And the error that costs six figures is usually two years old and started as a single termination that did not transmit.
What I am not. Not a broker, not a licensed insurance producer on this work, and not your attorney or your accountant. I do not take carrier commissions or overrides, which means nothing in my compensation depends on which carrier you use or how much premium you pay them. This audit identifies discrepancies and quantifies them. Decisions about plan administration, benefits owed, and corrections stay with the plan administrator and their advisors.
Confidentiality
How your data gets handled
Before anything moves
Mutual NDA signed first. A business associate agreement in place where protected health information is in scope, which for an enrollment and invoice audit it usually is.
Minimum necessary
I ask for eligibility and billing data, not claims detail. Where a finding can be proven with an employee ID instead of a name and a date of birth, that is what I ask for.
In transit and at rest
Encrypted transfer through your secure file portal or mine. No census files over regular email, including when somebody on your team offers.
When it is over
Working files are returned or destroyed at your instruction at the close of the engagement, and you get that confirmed in writing.
Questions I get
The honest answers
Does this replace my broker?
No, and your broker is usually glad this exists. Brokers are paid to place and service coverage. Nobody pays them to reconcile your invoice line by line against your enrollment system, and most of them are not staffed to do it even when they want to. I work alongside your broker, I will copy them on findings if you want that, and I am happy to hand them anything that belongs in their lane.
Will carriers actually talk to you?
Yes, with a letter of authorization from you naming me. That is a standard document and it goes out in week one. The authorization gives me eligibility and billing access only. I do not need and do not request claims authority.
Our data is a mess. Should we clean it up first?
Please do not. Cleaning the file before you send it removes exactly what I am hired to find, and it means you pay for an audit of a version of your data that does not exist in production. Send it the way it comes out of the system. If the extract itself cannot be produced reliably, that is a finding, and a significant one.
We are fully insured. Does this still matter?
It matters for the money. Fully insured means every phantom life and every wrong tier is premium you are paying for nothing, and that premium is recoverable only inside your carrier’s credit window. What you do not carry is the claims exposure that a self funded plan carries, which is why self funded groups usually add the stop loss cross-check and fully insured groups usually do not.
What if you do not find anything?
Then you have a clean documented baseline, a written statement that your three systems agree, and something to show an auditor or a CFO who asks. That is a real result and it is worth having. I will also tell you plainly that your quarterly spend is better directed elsewhere, because a group with genuinely clean data every quarter does not need me every quarter.
How is this different from the dependent eligibility audits we have been pitched?
A dependent eligibility audit asks your employees to prove their dependents qualify. It is a verification campaign aimed at your people. This is a systems audit aimed at your data, and it does not ask your employees for anything. Different tool, different problem. I offer a dependent review as an add-on when the enrollment match suggests it is warranted, which is not every group.
Can we just do this ourselves?
Some teams can, and I would rather tell you that than sell you something. If you have somebody who can hold 40 uninterrupted hours, read an 834 and a self-bill, and write a credit request that survives a carrier’s first no, do it in house. I also sell a reconciliation tool for teams who want to run the match themselves. What most teams do not have is the uninterrupted time, which is why the work keeps getting postponed to next quarter until it is out of the credit window.
How soon can you start?
I take a limited number of engagements per quarter so that credit requests get worked instead of queued. Tell me your situation and I will tell you the real next available start date rather than a nice-sounding one.
Next step
Start with the fit call
Twenty minutes, no charge, no deck. Send me an email and I will come back with a few times that work. Come to the call with your headcount, your carrier list, your funding arrangement, and how your enrollment data gets to your carriers. I will tell you where that setup usually breaks, what the audit would cost, and whether you need it at all.
Send one line about your situation, your headcount, and whether you are self funded or fully insured. You will get a reply within one business day with a few times that work and a short intake form.
Or write to me directly at ekirby@ericakirby.com.
I take a limited number of audit engagements each quarter.
ericakirby.com · Nobody Told Me That™ · Benefits, translated.
This page describes a benefits operations consulting service. It is not legal, tax, or actuarial advice.