Last Minute Heroics

A few years ago, I was finalizing an audit when the audit lead came to me and told me that he had discovered the the largest finding in the company's history.  He went on to declare that the issue he found would probably end up on the news because of the magnitude and severity of the case.

We were reviewing a health insurer and according to his finding, we were paying the largest hospital chain the insurer dealt with incorrectly.  In his random sample, he had uncovered two cases where the company failed to adhere to the contracted rates.  He asked me to perform some data analytics and to validate the incorrect claims payment.

If his finding was correct, then the company would have mispaid the hospital chain millions of dollars. This would have resulted in incorrect payments on the patients behalf as well and could have resulted in the insurer losing it's license in the state.

Using Data Analytics, I was able to obtain the necessary data to perform the analysis, but my analysis didn't support the leads findings.  Rather than mispaying the entire hospital chain, it appeared as if we were only mispaying a single hospital within the chain.

Adjusting my inquiry, I obtained new data.  Again, the results didn't suport the notion that we were mispaying the entire hospital.  Instead, it revealed that we were mispaying a sinlge unit at the hospital chain incorrectly.

Again we obtained new data and reperformed the analaysis.  After several more iterations, we eventually determined that a) for a period of 6 weeks, b) we paid out patient services c) at a specific unit, d) at a specific hospital within a chain IF the patient had a specific insurance plan. 

The issue that we thought was the largest finding in the company's history, it turned out to have been a minor bump.  In the end, the issue wasn't even recorded in the final audit report, but rather shared with management as a Do Not Report item.

This was a major success because by using ACL we were able to properly assess the actual risk posed by the discovery of the audit lead.  Imagine going to the audit meeting only to tell management that we had uncovered the largest finding in the company's history only to have them come back a few days later saying, "No you were wrong?"