Early Claim Audits Improve Recoveries

If you ask medical claim auditors about the best time to engage their services, many will say that it's preferable to audit early or routinely. The self-funded benefit plans of large corporate and nonprofit employers pay out thousands (or millions) of dollars each month. With outside vendors managing most claim administration these days, auditing is the best way for plan sponsors to conduct oversight and manage their claim payments. Continuing advances in technology and methods make it possible to review 100 percent of claim payments and check hundreds of data points on every claim paid.

General auditors are most commonly focused on finance and tax issues. Professionals who review medical claims often have backgrounds at large health plans in their claim processing operations. It adds a layer of medical coding and billing expertise that gives the audit financial and healthcare expertise. Such contributions can transform the value of a claim audit and make it a valued management tool. A vital member service component to accurate claim payments is that it ensures members are treated equally. There is no substitute for good plan management practices.

If you ask anyone who has managed a fund recovery request after claim payment errors turn up in an audit, they'll tell you that time makes it more challenging. It's another reason auditing routinely or monitoring continuously makes sense. It prevents million-dollar problems that providers may delay repaying. As medical and prescription costs continue to rise, expenditures will increase, and errors will become more costly individually and collectively. The best audit firms suggest processing system improvements to reduce future errors. Stopping patterns of mistakes is always helpful.

The trend towards outsourcing claim processing to third-party administrators and pharmacy benefit managers makes good sense when you leverage their provider relationships. But it creates a need for more active oversight. Even when processors make performance guarantees, it's wise to ensure they are met with confirmation from an independent third-party auditor. The best firms have audited every TPA or PBM and know how to make a clean-sweep review of your claim payments. It keeps your plan functioning ****ter and avoids overspending because of mistakes, even if the percentage rate is tiny.