No two self-funded health plans are alike, and medical claim audits need to be customized for each. It’s why a combination of electronic review and human expertise makes an equal impact on accuracy and results. It’s always better to review 100 percent of claims in a comprehensive review than random sampling. Finding an independent audit firm with the expertise and software to help is essential to a successful outcome. Health plan claim auditing requires specialized knowledge because it involves coding and other issues beyond numbers. It’s why specialist firms outperform general auditors.
There are many advantages for mid and large-size employers to self-fund their benefits plans and large sums of money are on the line. The common practice of outsourcing claim administration means running oversight is necessary. In an industry where a one to three percent error rate is common, there is much to be recovered depending on a plan’s size. Members also benefit when claims are paid more accurately and are treated the same. Fiduciary responsibilities and regulatory requirements are also in the mix, and auditing frequently and accurately keeps your plan on track to meet them satisfactorily.
When auditors design a claim review, they need to consider many factors and ensure they’re meeting your plan’s needs. A one-size-fits-all approach is seldom sufficient, and it takes a unique mix of electronic and human reviews to arrive at the best outcome. Audits are about details, and ensuring they’re covered will increase the value. Implementing a continuous monitoring service that keeps audit software running in the background also can make a favorable impact. Monthly reporting on claim payment mistakes and overpayments is the easiest way to make recoveries more in real-time.
Pharmacy benefit plans benefit from claims auditing just as much as medical plans, and there are one-of-a-kind opportunities. Compliance with formularies and discounts and rebates being honored is crucial, and auditors can confirm whether it’s happening. If name-brand medications are dispensed when generics are available, it’s an immediate opportunity for cost savings. The financial options can be substantial depending on the plan size and enrollees. Claim auditing began as a regulatory and compliance necessity and, through the years, has evolved into a valued strategic management tool.
