Which entities typically audit health care claims?

The correct answer indicates that health care claims are audited by a combination of state and federal agencies as well as private insurance companies. This is because the oversight and auditing of health care claims involve multiple layers of regulation and review to ensure compliance with laws and regulations, prevent fraud, and ensure the accuracy of reimbursements.

Federal agencies, such as the Centers for Medicare & Medicaid Services (CMS), play a critical role in auditing claims for federal programs. They set guidelines and monitor claims to ensure that payouts are correct and that beneficiaries are receiving appropriate services. State agencies also participate in the auditing process, especially concerning Medicaid and other state-funded health programs.

Private insurance companies conduct their own audits to manage claims and minimize losses due to fraud and errors. They are responsible for ensuring the accuracy of the claims submitted by healthcare providers against their policies.

The inclusion of all three types of entities—state and federal agencies and private insurance companies—reflects the complexity and multi-faceted nature of health care claims auditing, which is vital for maintaining the integrity of the healthcare financial system.