Claim Auditing Takes on a New Importance

What can an employer-funded health plan do best in the face of skyrocketing costs and extraordinary events (the coronavirus pandemic)? Several things exist, but reviewing claim payments should be near the top. Medical claim audits are an excellent plan management tool for many reasons. They provide oversight of third-party administrators, find and flag irregularities, and help ensure claims are paid consistently and correctly. Numerous financial and plan management benefits occur in the short and long term. Finding mistakes before they are million-dollar problems always helps.

Most specialist claim audit firms today double-check 100 percent of claims and review them from every possible angle. The power of its software and methods is unrivaled, and it has a system to overview a claim administrator’s process. The biggest and easiest fixes are systemic improvements that prevent future errors. But today is also common for individual issues to be flagged that are well suited to recovery, which includes overpayments of payment in error. Plans emerge from an audit much better, and typically the price for the service is much less than the recoverable errors it finds and reports.

Today’s claim audits also produce reports that are actionable and easy to understand. Compared to the less specific reporting that accompanied random-sample audits of years ago, it’s a change. Technological advances have made it possible to check more claims for more data points in less time. There’s also less human oversight needed because the electronic reviews are so thorough and accurate. Medical claim auditing is one of many things revolutionized by technology. The same goes for pharmacy claims; they deserve audits as frequently – different criteria to check but equally valuable.

Meeting fiduciary and regulatory requirements can be reasons to schedule an audit, but good plan management practices are even more important. The upside of reviewing 100 percent of prescription claim audits paid is significant and can provide added insight into trends. Some employer-funded plans run audit software continuously and monitor their payments in real-time. Monthly reporting alerts in-house staff to issues before claim administrators report them. It’s peace of mind and good management practices combined – an excellent way to avoid costly last-minute surprises.


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