System-side perspectives on the evolution of medical claims audits within Meghalaya State-sponsored health insurance scheme: A qualitative study

Background and objectives Description of design adaptation of medical claims audits as critical governance tools within State-funded insurance schemes remain limited. From a system-side perspective, this study examined the evolution of medical claims audits within Meghalaya’s Megha Health Insurance Scheme (MHIS), and how this evolution shaped system behaviour, problem-solving, and perceived scheme performance. Methods An exploratory qualitative design was used. Following review of administrative records, historical performance data, and scoping interactions with MHIS managers, 27 interviews (State administrators, insurers, health insurance experts, healthcare providers) and 3 non-formal interactions with State Nodal Agency leadership were conducted. Thematic analysis was done; findings were validated through health facility visits and a stakeholders meeting. Results Progressive adaptations of medical claims audits included risk-based targeted auditing using high-risk indicators, standardised documentation formats, increasing stringency of discrepancy tolerance thresholds and financial penalties. Stakeholders reported facility improvements (medicine availability, infrastructure, documentation quality), provider-level changes (motivation, digital record systems, clinical confidence), and reduced out-of-pocket expenditure for beneficiaries, alongside evolution of medical claims audits. Meanwhile, increased documentation burden, enrolment constraints, technological disruptions, and claims processing delays were also reported. Participants suggested the need for capacity building, sustained enforcement mechanisms (feedback loops), and iterative system refinement. Interpretation and conclusions In a complex, real-world health system context, medical claims audits led to improved standardisation and discipline of practices within MHIS, with design ability to navigate system constraints, learn, and scale. Medical claims audits served as an efficient problem-resolution, performance empowering instrument and an adaptive governance mechanism within MHIS.