The Limit Does Not Exist…

We’re heading toward the end of the fiscal year, and for many of us, it’s claims audit season! What better way to learn about work comp audits than from the movie Mean Girls. So, if you’re sitting there like Cady Heron trying to do Mathlete level calculations, wondering: How did we get this audit score? Who did this? Why did we only get 68% in subrogation?! Take a breath, grab your Burn Book (or maybe just your audit report), and let’s break it down.

We Audit on Wednesdays

How are audits performed? It depends. Audits can come from the carrier, the state, or an independent auditor. But not all audit scores are created equal. Comparing a state audit score to an independent audit is like comparing Regina George to Janice Ian. They are not the same.

If you are planning on performing audits annually, try to keep a regular interval. For example, if you complete the audit in June, try to stick to the same timeframe for the next audit.

Pro tip: Only compare like to like. State audits to state audits, independent to independent. Different audit types = different scoring rubrics.

It’s Not a Regular Audit, It’s a Cool Audit

The focus of the audit may vary based on who is auditing and why. State audits usually focus on making sure the injured worker is getting their rightful benefits (because, like, duh — benefit provisions are statutory, Gretchen). Meanwhile, independent audits may evaluate the quality of claims handling: Excess notified? Communicating clearly? Avoiding unnecessary drama (aka litigation)?

Check the fine print: Each audit category should be defined, and the scoring criteria should be clear — no vague “You can’t sit with us” energy here.

So Who Wins Spring Fling Queen?

How is the final score calculated? This is where it gets mathy (sorry, Cady). You might have a passing overall score, but don’t let that distract you from a failing grade in a key category. A 90% overall score sounds fetch… until you realize you got a 40% in disability management.

Take action: Review category-level scores with your TPA and make a plan. You can’t fix what you don’t acknowledge.

Other Audit Rules from The Plastics:

Sample Size Matters: Most audits pull a sample of your claims, not the entire population. Know how many and which years are being reviewed — otherwise, you’ll be blindsided like Regina when she was hit by that bus.

Not All Claims Qualify for All Categories: Got 100 claims? Maybe only 8 have subrogation potential. So only those 8 get scored in that category. Don’t freak out if not every claim shows up in every box.

Wrap-Up Calls Are Like the After-Party: If you’re offered an audit debrief with the auditor and your TPA, say yes! It’s your chance to understand how they scored things, and which categories and scores may have been appealed by the TPA.

Final Word?

Audits aren’t just about the score — they’re about the story your claims program is telling. So grab your pink highlighter (it’s Wednesday, after all), dive into your audit report, and make sure your program isn’t just surviving — it’s thriving.

And remember: The limit does not exist… when it comes to improving your audit outcomes.